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PubMed1996

Issues in the development and implementation of clinical pathways.

Issues related to the development and implementation of clinical pathways require thoughtful planning, collaborative teamwork, and an understanding of the evolutionary nature of this work. Creating an understanding of the purpose behind the development of these guidelines often is only the first issue to be considered. Other common issues include physician involvement, documentation, pathway development, variance data analysis and feedback, and integration with outcomes management activities. Successfully addressing these issues is an ongoing component of a clinical pathway program.

Critical Pathways↗

PubMed2005

Open set speech perception with auditory brainstem implant?

OBJECTIVE: Only a small percentage of auditory brainstem implant (ABI) recipients treated for neurofibromatosis type 2 (NF2) have proved capable of identifying words using only the sound from the ABI. Recently, the ABI was applied to a series of patients with no cochlear nerve or with cochlear disorders that could not benefit from a cochlear implant (i.e., cochlear nerve aplasia or posttraumatic avulsion) or whose benefit was or would be severely compromised. A significant number of these patients have proven capable of understanding speech, including effortless telephone use. In the present study, a series of psychophysical tests were administered to determine the cause of the difference in performance between tumor (T) and nontumor (NT) ABI patients. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Twenty patients with ABIs participated in the investigation. Ten were NF2 patients and 10 NT subjects. Patient ages ranged from 24 to 61 years. Eleven were males and nine females. INTERVENTION: Auditory rehabilitation in auditory disconnection caused by cochlea or cochlear nerve disorders. RESULTS: There was a significant correlation between modulation detection thresholds and speech understanding and a significant difference in modulation detection between T and NT patients. CONCLUSIONS: The difference in modulation detection between the two groups suggests a difference in the survival of specific cells in the cochlear nucleus that support modulation. The pattern of results indicates a separate pathway of auditory processing that is specialized for modulated sounds, and that pathway is critical for speech understanding. In NF2 patients, the tumor and surgery may selectively damage this pathway, resulting in poor speech recognition with prosthetic stimulation.

Adolescent↗

PubMed2004

Using checklists and reminders in clinical pathways to improve hospital inpatient care.

OBJECTIVES: To determine whether the quality of hospital inpatient care can be improved by using checklists and reminders in clinical pathways. DESIGN: Comparison of key indicators before and after the introduction of clinical pathways incorporating daily checklists and reminders of best practice integrated into patient medical records. SETTING AND PARTICIPANTS: The study, at Wimmera Base Hospital in Horsham, Victoria, included patients admitted between 1 January 1999 and 31 December 2002 with ST-elevation acute myocardial infarction (AMI) and patients admitted between 31 July 1999 and 31 December 2002 with stroke. MAIN OUTCOME MEASURES: Compliance with key process measures determined as best practice for each clinical pathway. RESULTS: 116 patients with AMI and 123 patients with stroke were included in the study. ST-elevation AMI. After introducing the clinical pathway program, percentage-point increases for treatment compliance were 21.4% (95% CI, 7.3%-32.7%) for patients receiving aspirin in the emergency department; 42.7% (95% CI, 26.3%-59.0%) for eligible patients receiving beta-blockers within 24 h of admission; 48.1% (95% CI, 31.4%-64.8%) for eligible patients being prescribed beta-blockers on discharge; 43.7% (95% CI, 28.4%-59.1%) for patients having fasting lipid levels measured; and 41.2% (95% CI, 19.0%-63.5%) for eligible patients having lipid therapy. Stroke. After introducing the clinical pathway program, percentage-point increases for treatment compliance were 40.7% (95% CI, 21.0%-60.2%) for dysphagia screening within 24 h of admission; 55.4% (95% CI, 32.9%-77.9%) for patients with ischaemic stroke receiving aspirin or clopidogrel within 24 h of admission; and 52.4% (95% CI, 33.8%-70.9%) for patients having regular neurological observations during the first 48 h after a stroke. There was a fall of 1.0 percentage point (ie, a difference of -1% [95% CI, -4.7% to 10.0%]) in the proportion of patients having a computed tomography brain scan within 24 h of admission. CONCLUSION: Significant improvements in the quality of patient care can be achieved by incorporating checklists and reminders into clinical pathways.

Critical Pathways↗

PubMed1998

Brave new world: case managers and the future of clinical pathways.

Since they were invented at Boston's New England Medical Center in 1985, clinical pathways have evolved from bulky academic documents to sophisticated computerized tools capable of integrating clinical and financial data. Even so, many institutions still fail to take full advantage of the opportunities clinical pathways represent. Because of the rapid pace at which new drugs and clinical techniques are developed, pathways must become more flexible and easier to update, experts say. That means introducing some type of automation to the pathway process. Another change in store for case management departments will be the increasing emphasis on using clinical pathways to help bridge the continuum of care, from physicians' offices through acute care to outpatient and even home health. Indeed, some experts predict that within the next decade it may well become illegal not to use pathways to treat certain populations of patients.

Boston↗

PubMedDate not supplied

Continuity of care prism process applied to the congestive heart failure population.

Emphasis in healthcare during the 1990s has been both to provide optimal wellness and function with quality in a cost-effective manner. The Continuity of Care Prism Process was developed to meet the need to guide clients along the continuum of care and to achieve continuity of care. Advanced practice nurses are the "expert" clinicians in a position to care manage clients and meet the financial and quality constraints currently being placed on healthcare agencies. In this article, the vehicle used to demonstrate the Continuity of Care Prism Process is a congestive heart failure clinical pathway.

Case Management↗

PubMed2006

Immune complexes alter cerebral microvessel permeability: roles of complement and leukocyte adhesion.

Immune complexes (ICs) are potent inflammatory mediators in peripheral tissues. However, very few studies have examined the ability of ICs to induce inflammatory responses in the brain. Therefore, using preformed ICs or the reverse passive Arthus (RPA) model to localize ICs to the pial microvasculature of mice, we aimed to investigate the ability of ICs to induce an inflammatory response in the cerebral (pial) microvasculature. Application of preformed ICs immediately increased pial microvascular permeability, with a minimal change in leukocyte adhesion in pial postcapillary venules. In contrast, initiation of the RPA response in the pial microvasculature induced changes in cerebral microvascular permeability and increased leukocyte adhesion in pial postcapillary venules. The RPA response induced deposition of C3 in perivascular regions adjacent to sites of IC formation. Depletion of C3 abrogated RPA-induced microvascular permeability and leukocyte adhesion, indicating that the complement pathway was critical for this response. Inhibition of leukocyte adhesion via CD18 blockade also reduced IC-induced microvascular permeability. However, this did not require intercellular adhesion molecule-1, inasmuch as blockade of intercellular adhesion molecule-1 did not alter RPA-induced microvascular permeability and adhesion. These findings demonstrate that ICs are capable of rapidly inducing inflammatory responses in the cerebral microvasculature, with the complement pathway and leukocyte recruitment playing critical roles in microvascular dysfunction.

Animals↗

PubMed1998

Pathway leadership: a mature framework for teams.

Shared Governance has been a successful organizational design for Central Baptist Hospital. We are addressing critical issues that impact our success, with involvement and facilitation of the employees who make up the organization. It will continue to change as our environment and system evolve. The movement from a traditional organizational structure and culture to one of embracing shared decision making gives leaders today an additional stressor. It is difficult to critically analyze your organization when you are faced daily with the external pressures of health care competition and the internal daily pressures of operations. It takes extra effort and introspection to recognize that you and your management team must undertake new and different behaviors to lead your organization into the next millennium. One thing is clear: If you do not create an environment that is flexible and able to accommodate change, your competitor will!

Communication↗

PubMed1988

Studies of surface immunoglobulin-dependent B cell activation.

Studies from a number of laboratories have firmly established the potential of surface immunoglobulin-generated signals in B lymphocyte activation. While clearly there are multiple ways of activating B lymphocytes, some of which may not involve surface immunoglobulin, it is clear that crosslinking of surface immunoglobulin whether by antigen or antireceptor antibody can generate signals relevant to B cell activation. Although considerable insight into the mechanism of transduction of mIg-generated signals across the plasma membrane has been realized, a molecular explanation for linking inositol phospholipid hydrolysis to changes within the cytoplasm and nucleus of the B cell is still speculative. A more rigorous definition of the PKC and calcium components of the mIg signal transduction pathway are critical for a thorough understanding of the mechanism of signal transduction by this receptor. The use of tumor cell models allowing selection of mutants within the signalling pathway(s) will be invaluable to fully defining the critical molecular and biochemical events involved in B cell activation.

Animals↗

PubMed1988

Protein C and the endothelium.

With the continued accumulation of clinical and animal studies, it is becoming abundantly clear that the protein C anticoagulant pathway plays a critical role in the regulation of coagulation. Investigations also indicate that this pathway is intimately involved in the interaction of the coagulation and inflammatory systems. Although no direct information is presently available, the function of this pathway is likely depressed in the regions of atherosclerotic plaque. It is clear that monocytes accumulate in this region and release many growth factors and monokines that are capable of endothelial function perturbation. Perturbation of the protein C anticoagulant pathway is one viable mechanism for the hypercoagulable state in this disease. As indicated here, the endothelial cells of the vessel wall play a critical role in the initiation, and possibly expression, of this pathway. Any injury to these cells that affects the proper expression of thrombomodulin, synthesis of protein S, or Factor Va inactivation complex formation could potentially lead to a hypercoagulable state and thrombotic complications. As has been discussed, several inflammatory mediators are already known that fulfill the criteria of endothelial cell perturbants that may lead to such a state. What other entities might have similar effects, either directly or indirectly through induction of cytokines, is not known at this time. A more complete understanding of this critical pathway and the effects of vascular disease on it should lead to a better understanding of many diverse disease processes and potential therapeutic strategies in the future.

Animals↗

PubMed2003

TAK1 is critical for IkappaB kinase-mediated activation of the NF-kappaB pathway.

Cytokine treatment stimulates the IkappaB kinases, IKKalpha and IKKbeta, which phosphorylate the IkappaB proteins, leading to their degradation and activation of NF-kappaB regulated genes. A clear definition of the specific roles of IKKalpha and IKKbeta in activating the NF-kappaB pathway and the upstream kinases that regulate IKK activity remain to be elucidated. Here, we utilized small interfering RNAs (siRNAs) directed against IKKalpha, IKKbeta and the upstream regulatory kinase TAK1 in order to better define their roles in cytokine-induced activation of the NF-kappaB pathway. In contrast to previous results with mouse embryo fibroblasts lacking either IKKalpha or IKKbeta, which indicated that only IKKbeta is involved in cytokine-induced NF-kappaB activation, we found that both IKKalpha and IKKbeta were important in activating the NF-kappaB pathway. Furthermore, we found that the MAP3K TAK1, which has been implicated in IL-1-induced activation of the NF-kappaB pathway, was also critical for TNFalpha-induced activation of the NF-kappaB pathway. TNFalpha activation of the NF-kappaB pathway is associated with the inducible binding of TAK1 to TRAF2 and both IKKalpha and IKKbeta. This analysis further defines the distinct in vivo roles of IKKalpha, IKKbeta and TAK1 in cytokine-induced activation of the NF-kappaB pathway.

Enzyme Activation↗

PubMed2003