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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↗
PubMed2002

Two different pathways for D-xylose metabolism and the effect of xylose concentration on the yield coefficient of L-lactate in mixed-acid fermentation by the lactic acid bacterium Lactococcus lactis IO-1.

In lactic acid bacteria, pentoses are metabolized via the phosphoketolase pathway, which catalyzes the cleavage of D-xylulose-5-phosphate to equimolar amounts of glyceraldehyde 3-phosphate and acetylphosphate. Hence the yield coefficient of lactate from pentose does not exceed 1.0 mol/mol, while that of Lactococcus lactis IO-1(JCM7638) at high D-xylose concentrations often exceeds the theoretical value. This suggests that, in addition to the phosphoketolase pathway, L. lactisIO-1 may possess another metabolic pathway that produces only lactic acid from xylose. In the present study, the metabolism of xylose in L. lactisIO-1 was deduced from the product formation and enzyme activities of L. lactisIO-1 in batch culture and continuous culture. During cultivation with xylose concentrations above ca. 50 g/l, the yield coefficient of L-lactate exceeded 1.0 mol/mol while those of acetate, formate and ethanol were very low. At xylose concentrations less than 5 g/l, acetate, formate and ethanol were produced with yield coefficients of about 1.0 mol/mol, while L-lactate was scarcely produced. In cells grown at high xylose concentrations, a marked decrease in the specific activities of phosphoketolase and pyruvate formate lyase (PFL), and an increase in those of transketolase and transaldolase were observed. These results indicate that in L. lactisIO-1 xylose may be catabolized by two different pathways, the phosphoketolase pathway yielding acetate, formate and ethanol, and the pentose phosphate (PP)/glycolytic pathway which converts xylose to L-lactate only. Furthermore, it was deduced that the change in the xylose concentration in the culture medium shifts xylulose 5-phosphate metabolism between the phosphoketolase pathway and the PP/glycolytic pathway in L. lactisIO-1, and pyruvate metabolism between cleavage to acetyl-CoA and formic acid by PFL and the reduction to L-lactate by lactate dehydrogenase.

Enzymes↗
PubMed1986

tert.-Butyl hydroperoxide metabolism and stimulation of the pentose phosphate pathway in isolated rat hepatocytes.

The metabolism of tert.-butyl hydroperoxide (TBHP) by the glutathione peroxidase/reductase system in isolated hepatocytes results in the rapid depletion of reduced glutathione and NADPH. The regeneration of NADPH can occur through the pentose phosphate pathway, but only when the pathway is stimulated, for example, by NADP+ and possibly oxidized glutathione, both of which can be elevated in hepatocytes exposed to TBHP. TBHP is a cytotoxicant and the role of NADPH and the pentose phosphate pathway in protecting hepatocytes from TBHP-induced injury is unknown. Isolated rat hepatocytes exposed to TBHP (0.5 mM) for 30 min metabolized more [1-14C]glucose to 14CO2 than control (638.2 +/- 96.2 vs 306.9 +/- 69.5 dpm/10(6) cells) whereas 14CO2 evolution from [6-14C]glucose was unchanged, indicating that TBHP increases the activity of the pentose phosphate pathway and not glycolysis. TBHP (0.25 mM) metabolism also resulted in a rapid oxidation of hepatocyte NADPH from 2.85 +/- 0.32 to 0.55 +/- 0.24 nmol/10(6) cells which rapidly returned to 3.58 +/- 0.27 nmol NADPH/10(6) cells. Inhibition of the pentose phosphate pathway with 6-aminonicotinamide (70 mg/kg; 5 hr prior to hepatocyte isolation) inhibited TBHP-stimulated 14CO2 evolution from [1-14C]glucose and decreased the rate of NADP+ reduction. Hepatocytes isolated from 6-aminonicotinamide-treated animals were more susceptible to TBHP-induced cell injury than were control hepatocytes. These data demonstrate the following: The metabolism of TBHP by isolated hepatocytes stimulated the activity of the pentose phosphate pathway; and inhibition of the pentose phosphate pathway with 6-aminonicotinamide potentiated the toxicity of TBHP to isolated rat hepatocytes. These results suggest that the regeneration of NADPH by the pentose phosphate pathway may play a significant role in protecting hepatocytes from TBHP-induced damage.

6-Aminonicotinamide↗
PubMed1994

Spatial working memory over long retention intervals: dependence on sustained cholinergic activation in the septohippocampal or nucleus basalis magnocellularis-cortical pathways?

Previous direct neurochemical studies of the temporal dynamics of cholinergic activation in the septohippocampal and nucleus basalis magnocellularis-cortical pathways at various stages during repeated testing of mice with selective spatial reference or working memory protocols [Durkin and Toumane (1992), Behav. Brain Res. 50, 43-52] showed that the post-test durations of cholinergic activation in each pathway varied as a function of the type of memory tested and the level of task mastery. Since (i) the hippocampal formation is considered to constitute a critical component of a temporary memory buffer, and (ii) working memory items are not thought to be submitted to consolidation and permanent storage, we postulated that the duration of testing-induced cholinergic activation in the septohippocampal pathway may govern the maintenance of the working memory trace over the retention interval. In order to test directly this hypothesis C57 B1/6 mice were extensively trained (one trial/day, 25-30 days) on an identical selective working memory task to attain high levels of retention (> 80% correct), but using either 5 min (Group 1), or 60 min (Group 2) retention intervals. At various times (30 s-75 min) following the initial acquisition phase of the test, cholinergic activity in the hippocampus and frontal cortex was quantified using measures of high-affinity choline uptake. Whereas cholinergic activation was observed in both pathways at 30 s post-acquisition and throughout the 5 min retention interval in Group 1, the situation in Group 2 is different, activation of the septohippocampal pathway being maintained for only 15 min, while activation in the nucleus basalis magnocellularis-cortical pathway is maintained for the totality of the 1 h retention interval. The nucleus basalis magnocellularis-cortical cholinergic pathway, in addition to its role in long-term reference memory storage processes may, thus, via an intervention in the temporal encoding of information, also subsume a complementary intermediate-term buffer storage role in working memory situations requiring retention intervals in excess of 15 min in mice. This secondary, "backup", function of the nucleus basalis magnocellularis-cortical pathway would thus liberate the septohippocampal complex from its primary active role in the temporary maintenance and/or accessibility of the working memory trace in these particular cases requiring long retention intervals.

Acetylcholine↗
PubMed2004

Clinical pathway care improves outcomes among patients hospitalized for community-acquired pneumonia.

PURPOSE: To examine the impact of a unique evidence-based clinical pathway on six outcomes of care in patients hospitalized for community-acquired pneumonia (CAP). METHODS: A retrospective cohort study of CAP patients discharged between January 1999 and December 2001, from 31 Adventist Health System institutions nationwide. A total of 22,196 records were available for multivariate analyses. Odds ratios (OR) for the outcomes were calculated and stratified by a unique severity score. The severity score ranged from 1 to 5, where 5 indicated the most severe condition. RESULTS: Pathway patients were significantly less likely to die in-hospital compared with non-pathway patients in four of the five severity strata (OR in severity level 1=0.37; 95% confidence interval [CI], 0.20-0.70). In all severity strata, pathway patients were approximately twice as likely as non-pathway patients to receive blood cultures and appropriate antibiotic therapy. Among patients who were classified as severity level 1, pathway patients experienced an 80% reduction in the odds of respiratory failure requiring mechanical ventilation (OR=0.20; 95% CI, 0.12-0.33). CONCLUSIONS: Patients who were placed on pneumonia clinical pathway care were much more likely than non-pathway patients to have favorable outcomes of care.

Adolescent↗
PubMed2006

Patient perception of a clinical pathway for laparoscopic foregut surgery.

Clinical pathways have been implemented for a number of surgical procedures, yet few data are available that explore the patients' perception of these changes in clinical practice. A clinical pathway was developed for laparoscopic fundoplication, Heller myotomy, and paraesophageal hernia repair. Data collected from a cohort of patients undergoing surgery with the pathway over a 12-month period was compared with a group of patients operated on in the 12 months prior to pathway implementation. A questionnaire examining patient-based outcomes and perceptions was completed 6 weeks after surgery. From November 2001 through November 2003, 49 patients underwent primary laparoscopic foregut surgery, 27 before and 22 after pathway implementation. There were no differences in age, gender, procedure, or ASA Class. Parenteral opioid use diminished significantly without compromising the patients' perceived pain control. The number of patients undergoing postoperative investigations diminished, as did length of stay. Of the 20 post-pathway patients completing satisfaction questionnaires, 95% were satisfied or very satisfied with their care during admission. Pathway implementation resulted in a significant reduction in direct postoperative hospital costs. A clinical pathway for laparoscopic foregut surgery was successfully implemented in a single-payer system, resulting in decreased utilization of hospital resources while maintaining high patient satisfaction.

Adult↗
PubMed2005

A clinical pathway for bronchiolitis is effective in reducing readmission rates.

OBJECTIVE: To examine the use of a clinical pathway in the management of infants hospitalized with acute viral bronchiolitis. STUDY DESIGN: A clinical pathway with specific management and discharge criteria for the care of infants with bronchiolitis was developed from pathways used in tertiary care pediatric institutions in Australia. Two hundred and twenty-nine infants admitted to hospital with acute viral bronchiolitis and prospectively managed using a pathway protocol were compared with a retrospective analysis of 207 infants managed without a pathway in 3 regional and 1 tertiary care hospital. RESULTS: Readmission to hospital was significantly lower in the pathway group (P = .001), as was administration of supplemental fluids (P = .001) and use of steroids (P = .005). There were no differences between groups in demographic factors or clinical severity. The pathway had no overall effect on length of stay or time in oxygen. CONCLUSIONS: A clinical pathway specifying local practice guidelines and discharge criteria can reduce the risk of readmission to hospital, the use of inappropriate therapies, and help with discharge planning.

Acute Disease↗
PubMed2006

Differential nicotinic regulation of the nigrostriatal and mesolimbic dopaminergic pathways: implications for drug development.

Neuronal nicotinic acetylcholine receptors (nAChRs) modulate dopaminergic function. Discovery of their multiplicity has lead to the search for subtype-selective nAChR agonists that might be therapeutically beneficial in diseases linked to brain dopaminergic pathways. The regulation and responses of the nigrostriatal and mesolimbic dopaminergic pathways are often similar, but some differences do exist. The cerebral distribution and characteristics of various nAChR subtypes differ between nigrostriatal and mesolimbic dopaminergic pathways. Comparison of nicotine and epibatidine, two nAChR agonists whose relative affinities for various nAChR subtypes differ, revealed differences in the nAChR-mediated regulation of dopaminergic activation between these dopamine systems. Nicotine preferentially stimulates the mesolimbic pathway, whereas epibatidine's stimulatory effect falls on the nigrostriatal pathway. Thus, it may be possible to stimulate the nigrostriatal pathway with selective nAChR agonists that do not significantly affect the mesolimbic pathway, and thus lack addictive properties. Furthermore, dopamine uptake inhibition revealed a novel inhibitory effect of epibatidine on accumbal dopamine release, which could form a basis for novel antipsychotics that could alleviate the elevated accumbal dopaminergic tone found in schizophrenia during the active psychotic state. Different regulation of nigrostriatal and mesolimbic dopaminergic pathways by nAChRs could be an important basis for developing novel drugs for treatment of Parkinson's disease and schizophrenia.

Animals↗
PubMed1998

An evidenced-based clinical pathway for acute appendicitis decreases hospital duration and cost.

BACKGROUND/PURPOSE: In the pediatric population, appendicitis remains the most common surgical emergency encountered. The purpose of this study was to determine the impact of an evidence-based clinical pathway for acute appendicitis on patient care as well as hospital and home care costs at the authors' pediatric institution. METHODS: A prospective evaluation was conducted of an appendicitis clinical pathway (June 1996 through November 1996) compared with historical control patients (June 1994 through November 1994) not cared for by the pathway. RESULTS: Data (average +/- SD) for 120 pathway (P) patients were compared with 122 control (C) patients. Age (11.5 +/- 3.6 years for C v 11.2 +/- 3.9 years for P), rates of negative appendectomy (12.3% for C v 9.2% for P) and perforation (26.2% for C v 18.3% for P) were similar. Pathway patients with nonperforated appendicitis were more often discharged from the hospital within 24 hours (48% for C v 67% for P; P = .014) with lower hospital costs ($4,095 +/- $1,280 for C v $3,638 +/- $1,633 for P; P = .001). Pathway patients with perforated appendicitis had shorter hospitalization (185.2 +/- 59 hours for C v 113 +/- 44 hours for P; P = .0001) and lower hospital costs ($11,175 +/- $3,893 for C v $7,823 +/- $2,366 for P; P = .0001). CONCLUSION: An evidence-based appendicitis pathway decreased duration of hospitalization and cost without adversely affecting diagnosis or therapy. Clinical pathways for surgical diagnoses may prove useful as a means to minimize costs without compromising patient care.

Acute Disease↗
PubMed1997

Implementation of a clinical pathway decreases length of stay and hospital charges for patients undergoing total colectomy and ileal pouch/anal anastomosis.

BACKGROUND: Clinical pathways are increasingly being used by hospitals to improve efficiency in the care of certain patient populations; however, little prospective data are available to support their use. This study examined whether using a clinical pathway for patients undergoing ileal pouch/anal anastomosis, a complex procedure in which we had extensive practical experience, affected hospital charges or length of stay (LOS). METHODS: A clinical pathway was developed to serve patients undergoing elective total colectomy and ileal pouch/anal anastomosis. All operations were performed by two attending physicians (J.E.F., M.S.N.). Before implementation, 10 pilot patients were prospectively monitored to ensure that hospital charges were accurately generated. In addition, charge audits were performed by an outside agency to verify the accuracy of the hospital bills. The pathway was then implemented, and 14 patients were prospectively analyzed. RESULTS: In all patients the principal diagnosis was ulcerative colitis, with the exception of three patients with familial polyposis. Mean external audit charges were within 2% of the hospital bills; therefore the hospital bills were used in all calculations. The mean LOS decreased from 10.3 days to 7.5 days (p = 0.046) for patients on the pathway versus pilot patients. Mean hospital charges also decreased significantly, from $21,650 to $17,958 per patient (p = 0.005). CONCLUSIONS: Implementation of a clinical pathway, even for an operation in which the surgeon has much experience, is an effective method for reducing LOS and charges for patients. This is likely the result of interdisciplinary cooperation, elimination of unnecessary interventions, and streamlined involvement of ancillary services. These results support the development of clinical pathways for procedures that involve routine preoperative and postoperative care. In addition, the benefits of clinical pathways should increase proportionally with increasing case volume for a particular procedure.

Adenomatous Polyposis Coli↗
PubMed2000

Control of the classical and the MBL pathway of complement activation.

The activation of complement via the mannan-binding lectin (MBL) pathway is initiated by the MBL complex consisting of the carbohydrate binding molecule, MBL, two associated serine proteases, MASP-1 and MASP-2, and a third protein, MAp19. In the present report we used an assay of complement activation specifically reflecting the physiological activity of the MBL complex to identify biological and synthetic inhibitors. Inhibitor activity towards the MBL complex was compared to the inhibition of the classical pathway C1 complex and to a complex of MBL and recombinant MASP-2. A number of synthetic inhibitors were found to differ in their activities towards complement activation via the MBL pathway and the classical pathway. C1 inhibitor inhibited both pathways whereas alpha2-macroglobulin (alpha2M) inhibited neither. C1 inhibitor and alpha2M were found to be associated with the MBL complex. Upon incubation at 37 degrees C in physiological buffer, the associated inhibitors as well as MASP-1, MASP-2, and MAp19 dissociated from MBL, whereas only little dissociation of the complex occurred in buffer with high ionic strength (1 M NaCl). The difference in sensitivity to various inhibitors and the influence of high ionic strength on the complexes indicate that the activation and control of the MBL pathway differ from that of the classical pathway. MBL deficiency is linked to various clinical manifestations such as recurrent infections, severe diarrhoea, and recurrent miscarriage. On the other hand, impaired control of complement activation may lead to severe and often chronically disabling diseases. The results in the present report suggests the possibility of specifically inhibiting of the MBL pathway of complement activation.

Animals↗
PubMed1998

Mapping of neural and signal transduction pathways for lordosis in the search for estrogen actions on the central nervous system.

Estrogen can act on the brain to regulate various biological functions and behavior. In attempts to elucidate the estrogen action, the rodent female reproductive behavior, lordosis, was used as a model. Lordosis is an estrogen-dependent reflexive behavior and, hence, is mediated by discrete neural pathways that are modulated by estrogen. Therefore, a strategy of mapping the pathways, both neural and biochemical, and examining them for estrogen effect was used to localize and subsequently analyze the central action of estrogen. Using various experimental approaches, an 'inverted Y-shaped' neural pathway both sufficient and essential for mediating lordosis was defined. The top portion is a descending pathway conveying the permissive estrogen influence which originated from hypothalamic ventromedial nucleus relayed via midbrain periaqueductal grey down to medullary reticular formation, the top of the spino-bulbo-spinal reflex arc at the bottom. This estrogen influence alters the input-output relationship, shifting the output toward more excitation. With this shift in output, estrogen can enable the otherwise ineffective lordosis-triggering sensory stimuli to elicit lordosis. In the ventromedial nucleus, the origin of the estrogen influence, a multidisciplinary approach was used to map intracellular signaling pathways. A phosphoinositide pathway involving a specific G protein and the activation of protein kinase C was found to be involved in the mediation of lordosis as well as a probable target of the permissive estrogen action. The action of estrogen on this signal transduction pathway, a potentiation, is consistent with and, hence, may be an underlying mechanism for the estrogen influenced shift toward excitation. Thus, further investigation on this specific signal transduction pathway should be helpful in elucidating the action of estrogen on the brain.

Animals↗
PubMed2001

Tau, beta-amyloid and beta-amyloid precursor protein distribution in the entorhinal-hippocampal alvear and perforant pathways in the Alzheimer's brain.

It has been suggested that the pathological lesions of Alzheimer's disease (AD) spread along neuronal connections. This study was designed to examine this hypothesis in the alvear and perforant pathways, two well-defined neuroanatomical pathways that project from the entorhinal cortex to the hippocampus. Paraffin-sections of hippocampal-entorhinal cortex from 25 AD cases were immunolabelled for tau, beta-amyloid (Abeta) and beta-amyloid precursor protein (betaAPP). We used image-analysis to quantify immunolabelling at both ends of the alvear and perforant pathways. At the beginning and the end of the alvear pathway, area of immunolabelling in microm2 per area of field (72000 microm2) were as follows: tau 349 and 821 (P<0.01), Abeta 349 and 61 (P<0.05) and betaAPP 18 and 73 (P<0.01). Corresponding values for the perforant pathway were tau 421 and 387, Abeta 382 and 115 (P<0.05) and betaAPP 55 and 83. Tau was significantly greater at the end than at the beginning of the alvear pathway, but similar at both ends of the perforant pathway. There was significantly more Abeta at the beginning than at the end of the alvear and perforant pathway. These results at least in part reinforce previous work [19] that tau-rich areas may be neuronally connected to Abeta-rich areas.

Aged↗
PubMed1987

Reliability of retrograde atrial activation patterns during ventricular pacing for localizing accessory pathways.

Definitive localization of accessory pathways is based on atrial activation patterns during orthodromic supraventricular tachycardia when retrograde conduction occurs exclusively through the accessory pathway. In some patients, supraventricular tachycardia cannot be induced or is deleterious. To determine whether accessory pathway sites can be identified accurately during ventricular pacing, retrograde atrial activation was assessed during orthodromic supraventricular tachycardia and ventricular pacing at multiple cycle lengths in 41 patients with a single accessory pathway. To obviate retrograde fusion due to concomitant conduction through the normal atrioventricular (AV) conduction system that may obscure the location of the accessory pathway, the difference in conduction time from the site of earliest atrial activation to the His bundle atrial electrogram (delta A-SVT) was measured during orthodromic supraventricular tachycardia and compared with values observed during ventricular pacing (delta A-VP). Characteristic values for the delta A-SVT interval were identified for left lateral (66 +/- 17 ms), left posterior (50 +/- 8 ms), posteroseptal (33 +/- 7 ms), right free wall (22 +/- 15 ms) and anteroseptal (0 +/- 0 ms) accessory pathway sites. During ventricular pacing, the site with the earliest atrial electrogram was used to define the accessory pathway location only if the maximal value of the delta A-VP interval over the range of cycle lengths assessed was comparable with the value of the delta A-SVT interval characteristic of that region. Values of the delta A-SVT interval correlated closely with the maximal values of the delta A-VP interval (r = 0.91). With this approach, 40 (98%) of 41 accessory pathway sites were identified correctly during ventricular pacing.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1997

Utility of clinical pathway and prospective case management to achieve cost and hospital stay reduction for aortic aneurysm surgery at a tertiary care hospital.

PURPOSE: We reviewed our experience with a clinical pathway instituted in December 1993 for all nonurgent abdominal aortic aneurysm (AAA) surgery. METHODS: We analyzed a reference group of 49 consecutive pre-pathway AAA patients (group I) and the 44 patients enrolled in the first year of the pathway (group II). On the basis of the interim review of data collected during the first year, pathway modifications were made, and 34 patients enrolled after these modifications (group III) were also analyzed. RESULTS: Comparison of groups I and II showed that institution of the pathway resulted in a marginally significant reduction in mean charges of 14.7% (p = 0.09), and a slight fall in mean length of stay (LOS) (13.8 vs 13.1 days, NS) and mortality rate (4.1% vs 2.3%, NS). For group II, a significant correlate (p < 0.05) of increased charges was fluid overload as diagnosed by chest radiograph. This recognition led to active efforts to reduce perioperative fluid administration. Comparison of groups II and III revealed that the practice modifications led to marked reduction in the incidence of fluid overload (73% vs 24%; p < 0.01), mean charges (30.4% reduction; p < 0.05), mean LOS (13.1 vs 10.2 days; p < 0.05), and median LOS (11 vs 8 days). Multiple regression analysis of all pathway patients showed that preoperative renal insufficiency is a significant predictor of both increased LOS (p < 0.01) and charges (p < 0.01), but that age, sex, and coronary disease were not predictive. Of the postoperative parameters analyzed, important correlates of increased charges were acute renal failure (p < 0.01) and fluid overload (p < 0.01). CONCLUSIONS: Institution of a clinical pathway for AAA repair resulted in significant charge reduction and a slight reduction in stay. Practice modifications based on interim data analysis yielded further significant reductions in charges and LOS, with overall per-patient charge savings (group I vs III) of 40.6% (p < 0.05) and overall LOS reduction of 3.5 days (p < 0.05). The reduction in actual charges was seen despite an overall increase in the hospital rate structure. Comparing groups I, II, and III, we found no indication of increasing mortality rate. Ongoing analysis has identified correlates of increased charges, potentially permitting identification of high-cost subgroups and more focused cost-control efforts. Rather than restricting management, clinical pathways with periodic data analysis may improve quality of care.

Aortic Aneurysm, Abdominal↗
PubMed2003

Integrated care pathway: the prevention and management of pressure ulcers.

The introduction of this pathway for the prevention and management of pressure ulcers was influenced by the development of the pathway for the management of a patient with a fractured neck of femur. Systematic documentation of preventative measures for patients with a fractured neck of femur helped reduce the incidence of pressure ulcers in this high-risk group. The original draft was informed by evidence-based clinical practice guidelines. This draft of the pathway was piloted, reviewed and changed in line with current evidence and comments from users. It was invaluable to pilot the pathway and review as necessary in order to make this a true workable document that would enable continuity of care, help prevent hospital-acquired pressure ulcers and be an effective teaching aid. A trust-wide retrospective audit of documentation for the prevention and management of pressure ulcers has been conducted, which found that the pathway facilitated a more concise approach to inform care than standard documentation. A further audit has been undertaken in the care of the elderly directorate which has demonstrated various ways in which the pathway had been completed. Challenges remain for the effective use of this documentation. Further education needs to be completed in order to promote multiprofessional use of the pathway. The pathway is now being integrated into others, which will increase awareness and involvement of other professional groups in this important aspect of patient care. Ongoing audit will take place to assess the impact upon patient outcomes.

Activities of Daily Living↗
PubMed2002

Effect of support programme to reduce stress in spouses whose partners 'fall off' clinical pathways post cardiac surgery.

Cardiac surgery is flourishing in today's health care industry and looks to prosper well into the future. More than ever, improved technology, surgical skill and the worldwide trend of increasing longevity means that surgical intervention is offered to patients rarely seen in cardiac units in previous years. Patients are now much older, with multiple co-morbidity including repeat cardiac surgery. In line with advances in cardiac surgery, critical pathways to map the expected recovery route for the patient have been introduced. These maps are used extensively as guides for treatment and care. It is not only health professionals who use the pathways; patients and their relatives also refer to them as indicators of a 'normal' post-operative route. As a result, the critical pathway provides an avenue for expectations of predicted progress through to discharge. These predictors appear to give spouses hope, access to earliest possible visitation and confidence in a positive outcome. Nevertheless, it has recently become increasingly clear that for partners of patients who fail to proceed as expected, who apparently 'fall off' the predicted road to recovery, the critical pathway is problematic. Partners of such patients tend to demonstrate greatly heightened anxiety and nurses often have to deal with them at the point of crisis. In the cardio-thoracic unit at which this study was undertaken, the significant number of spouses who ended up in crisis drew attention to the need for additional support to be built into the post open-heart surgery critical recovery pathway. This study sought therefore to examine how nurses might assist spouses to adapt in the event of a complicated recovery following bypass surgery. A convenience sample of 39 spouses of cardiac surgical patients admitted to the cardio-thoracic recovery unit was obtained to assess stress responses at a critical post-operative data point, 5 days post-surgery. A symptoms of stress inventory was used to measure 94 items of physiological stress in 10 specific subscale categories. As a result of this study, it was found that incorporating a spousal support programme into the critical pathway of open-heart surgical patients significantly reduced stress suffered by spouses of patients who deviated from pre-determined recovery goals. The findings suggest that nurses need to understand the implications of the critical pathway and provide families with information concerning issues associated with complicated recovery. An unexpected finding of the study pointed to an apparent difference in the stress experienced by male spouses to that of female spouses. Recommendations from this study are to further explore the qualitative component of the stress felt by spouses and the negative association of stress with morbidity and mortality for women and patients without spouses. Nurses need to consider developing and implementing a stress management programme for spouses, establishing spousal support groups and exploring the possibility of incorporating spousal support strategies into the critical pathways of patients across hospital settings.

Adult↗
PubMed1997

The development and implementation of an integrated multidisciplinary clinical pathway.

Clinical pathways, linear time-related representations of patient care processes, are widely encouraged as a mechanism to outline efficient, cost-effective, multidisciplinary care. The translation of pathways from concept to reality is, however, predictably difficult. All caregivers are dedicated to a common goal, but organizational, personal, and professional perspectives are barriers to development of a common tool. Moreover, the building process requires the discovery, articulation, and communication of previously tacit patient care processes. Although no prescription can work for all pathway development, some strategies can help ensure the best possible chance of pathway success. Participants must recognize that between-patient variability can be expected to decrease with pathway implementation, and educational processes must support that aim. "Stakeholder groups" must be identified and their investment must be assessed, with careful attention paid to acquiring the unconditional support of institutional leadership. Planning of precise building, implementation, and piloting processes, with provision for facilitation of building and implementation processes, is critical. Those charged with pathway development must commit to the establishment and explication of clear goals (economic and quality outcomes) and to careful integration of the pathway with planned and existing continuous quality improvement processes. These strategies are illustrated with actual experiences in implementing cystectomy and pressure ulcer pathways in one academic medical center.

Communication↗