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The effects of the critical pathway for inguinal hernia repair.
This study was conducted to develop a case management program using the critical pathway (CP) as an intervention method for patients with an inguinal hernia for a herniorrhaphy, and to determine the effects of the CP on the period of hospitalization, medical costs, the rates of postoperative complaints, patient satisfaction and the nurses' job satisfaction. One hundred patients (60 in the experimental group, 40 in the control group) who were admitted to a general hospital in Seoul for inguinal herniorrhaphy were enrolled in this study. The results showed that the period of hospitalization and the postoperative hospital stay were significantly reduced in the CP group. In addition, the total medical cost, was lowered significantly by use of the CP for patients undergoing an inguinal herniorrhaphy. The rates of postoperative complaints, patients' satisfaction and the information on the treatment were enhanced after implementing the CP. These results suggests that the CP may be a useful tool for enhancing the health care outcome by decreasing the period of hospitalization, overall medical costs and by improving the quality of care, all of which can benefit the patients, the patients' family, caregivers and the hospital.
Adolescent↗
Critical pathways using platelet testing to potentially optimize the use of oral antiplatelet therapy.
Although monitoring anticoagulation is standard practice, monitoring antiplatelet therapy has not yet widely been adopted as a means of assessing antithrombotic response. However, bedside devices have recently become available that facilitate more rapid assessment of antithrombotic response, allowing this information to be developed into a critical pathway. Three major opportunities exist for oral antiplatelet therapy: (1) optimizing the dose of aspirin for long-term therapy; (2) optimizing the dose of clopidogrel, especially in percutaneous coronary intervention, acutely and during long-term therapy; and (3) evaluating the level of platelet inhibition before coronary artery bypass grafting or other major surgery. Several critical pathways are proposed that may assist clinicians in trying to ensure adequate platelet inhibition in these important clinical situations.
Administration, Oral↗
Radical outcome method. A new approach to critical pathways in congenital heart disease.
BACKGROUND: Treatment of congenital heart disease has entered a new era of healthcare delivery and cost containment. Critical pathway method (CPM) has been previously demonstrated by us to produce a significant reduction in average length of stay (ALOS) in hospital of -44%. A new approach, radical outcome method (ROM), has produced comparable results that appear to improve over time. The dynamic nature is examined. METHODS AND RESULTS: Two hundred consecutive patients with congenital heart disease were treated by a single surgeon at a single health maintenance organization (HMO) facility. ROM was used in all patients. This method uses seven critical moments at which shortening rather than confirmation of the ALOS is possible. This process is completed by the second post-operative day. Overall mortality was 1%. The 200 patients were divided into two consecutive groups of 100 patients to determine the effectiveness of ROM over time. Fifty sets were matched. ALOS hospital decreased by 29 days (mean, 0.6 d/set), P < .003. Thirty sets who underwent cardiopulmonary bypass had a 16% decrease (P < .03), and 20 sets in whom nonbypass procedures were performed had a decrease of 16% (P < .02). ALOS in hospital for the 50 sets decreased from 3.7 to 3.1 days (-16%, P < .003). Outcome data demonstrated no significant difference. CONCLUSIONS: ROM, a proactive approach to hospital stay, is a dynamic process that reduces ALOS in hospital. This is achieved by both reducing negative variation in the standard CPM and allowing for positive variation. Outcome data confirm that this approach can reduce ALOS in hospital while providing optimal patient care and family satisfaction, a standard for the new era of healthcare delivery.
Cardiopulmonary Bypass↗
Impact of a critical pathway on the results of carotid endarterectomy in a tertiary care university hospital: effect of methods on outcome.
PURPOSE: A carotid endarterectomy critical pathway (CP) targeting a 3-day postoperative course was introduced in March 1994. This retrospective analysis assesses its impact on operative results, postoperative length of stay (POD), and cost of hospitalization (COH). METHODS: One hundred eighty-six patients who underwent 201 carotid endarterectomy procedures from Nov. 1992 to Feb. 1994 (Pre-CP; n = 67) and from Apr. 1994 to Jul. 1995 (Post-CP; n = 134) at Johns Hopkins Hospital, a tertiary care referral center, were evaluated. RESULTS: The Pre-CP and Post-CP groups had similar risk factors, postoperative morbidity rates, and mortality rates. Furthermore, they had similar mean POD (Pre-CP, 6.0 +/- 0.5 days; Post-CP, 5.7 +/- 0.6 days; p = 0.79) and COH. However, only 85 of the Post-CP (63%) patients were actually placed on the CP (CP-starters); the mean POD was 3.4 +/- 0.3 days among these CP-starters (p < 0.0001) and 2.8 +/- 0.1 days among the 74 Post-CP patients (55%) that remained on the pathway (CP-finishers; p < 0.0001). The mean COH was reduced from $12,881 (Pre-CP) to $9701 for the CP-starters (p = 0.01) and to $8572 for the CP-finishers (p = 0.0001). However, we found that only 47 of the Pre-CP patients (70%) would have been eligible for the CP, and the mean POD among those cases was 4.2 +/- 0.4 days, which was not different than the mean POD among the CP-starters (p = 0.17). The mean COH of the eligible Pre-CP cases, $9508, was not significantly different from the COH of the CP-starters (p = 0.97). CONCLUSIONS: This subset analysis emphasizes the importance of establishing an accurate "control" group when studying a CP, because using all of the Pre-CP cases as the "control" group in the original analysis, including patients who would not have been candidates for the CP, clearly overstated the beneficial impact of the CP.
Analysis of Variance↗
Critical pathways can improve results with carotid endarterectomy.
Approximately 10 years ago, the Section of Vascular Surgery at Pennsylvania Hospital reported results of critical pathways that we developed for all major vascular operations, including carotid endarterectomy (CEA). After implementing these pathways, we then developed a specific five-step protocol to further improve results and decrease costs for elective CEA. With the advent of carotid artery balloon angioplasty and stenting (CABAS), CEA has come under increasing attack by endovascular interventionalists. We believe our regimen remains the gold-standard against which CABAS should be compared. Our five-step CEA protocol includes: (1) duplex ultrasonography performed in an accredited vascular laboratory as the sole diagnostic carotid preoperative study, (2) admission the day of surgery, (3) cervical block anesthesia to eliminate intraoperative electroencephalographic monitoring and other costly intraoperative monitoring tests, (4) transfer from the recovery room after a short observation period to the vascular ward, and (5) discharge the first postoperative morning. Since this 5-step protocol was implemented several years ago, we have found it to be safe and cost-effective, and now represents the standard against which CABAS should be compared.
Aged↗
Critical pathways and mother-baby coupling.
Mother-baby couplet care has been utilized for more than 10 years. Both staff and patients find use of critical pathways in this managed care system to be very effective and efficient.
Critical Pathways↗
Want more recognition for your critical pathways?
Case managers at the Daniel Freeman Memorial Hospital in Inglewood, CA, planned a "celebration of success" earlier this year to highlight their accomplishments. Individual critical pathways teams presented data for their different areas, such as orthopedics and cardiac surgery. Team members were able to educate staff about their efforts and show off their accomplishments to administrators. It was so successful, that another celebration is planned for next year.
Anniversaries and Special Events↗
Critical pathway. An effective way to manage care of the insulin-dependent diabetic.
Critical pathways are recommendations for delivery of care. They can encompass all facets of treatment, from clinical care to patient education. In light of the growing prevalence of managed care, clinical pathways and outcomes measurement increasingly will interest both providers and payors as they strive for cost-effective yet top-quality patient care.
Clinical Protocols↗
[Critical pathway for the treatment of acute myelogenous leukemia].
Based on analysis of data from 10 patients newly diagnosed as having acute myelogenous leukemia (AML), we developed a critical pathway (CP) to prevent infection and thus shorten the period of hospitalization. This CP shows laboratory test results, vital signs, chemotherapy regimen, concomitant supportive care and oral medications, gargling with antiseptic mouthwash, other anti-infection measures, diet, room conditions, patient education in anti-infection measures, outcome, and variance on the vertical axis and time on the horizontal axis. After introduction of the CP, 9 of the newly diagnosed AML patients did not experience severe treatment-related complications during a mean hospitalization of 29 days until remission and 95 days until discharge. These results suggest that the present CP makes it possible to shorten the hospital stay, reduce treatment costs, and improve the quality of life of AML patients.
Acute Disease↗
Critical pathway and patient and family teaching protocol for major depression.
The pressures to contain cost, reduce resource consumption, and articulate outcomes will continue in psychiatric-mental health care. Case management and critical pathways focused on outcome management are systems and tools used to provide care in a cost-effective manner while maintaining the quality of patient care.
Critical Pathways↗
Developing critical pathways containing antimicrobial therapy.
Today's health care institutions are being challenged to provide high quality health care in the most efficient way possible. One approach taken by many organizations has been the development of critical pathways in order to minimize delays in therapy, facilitate the best outcomes, optimize resources, and maximize quality. Opportunities exist for these protocols to address a number of antimicrobial therapy issues and the multidisciplinary development process provides an excellent opportunity for pharmacist involvement.
Algorithms↗
A critical pathway for patients undergoing one-day breast cancer surgery.
As the trend of surgical procedures shifting from inpatient to outpatient settings continues, outpatient-focused standardized care processes will become more of a necessity. A multidisciplinary critical pathway (CP) for breast cancer surgery can assist care providers in meeting patients' educational and psychosocial needs. The CP document discussed in this article takes into account the expedient nature of outpatient surgery and spans the continuum of care from the surgical clinic to the postoperative homecare visit. Integrating homecare nursing improves the quality and consistency of care.
Ambulatory Surgical Procedures↗
Poisoning and toxic effects of drugs: a critical pathway for improving outcomes.
Increasing cost constraints and the continuous need to enhance quality has focused attention on developing and implementing programs to improve patient care delivery. Case management programs enable organizations to balance quality components with costs to improve outcomes for patient populations. Critical pathways can be utilized as a tool for promoting optimal outcomes for case managed populations in acute care hospitals.
Critical Pathways↗
Will critical pathways replace the nursing process?
Individualised care is the essence of nursing and regard for the individual is the battle against the impersonal institution. Unfortunately, attempts to manage the process of individualised care have often ended in failure (Ford and Walsh 1994). Some observers maintain that the rigid behaviour which characterises the nursing process contradicts the intuitive nature and individualistic approaches which are fundamental to nursing practice (Benner 1984). This article reviews the concept of critical pathways, a new approach to managing patient care.
Cooperative Behavior↗
Designing a carotid endarterectomy critical pathway for your organization.
BACKGROUND: Carotid endarterectomy (CEA) is one of the top-five surgical diagnosis-related groups at Keesler Medical Center. The geometric mean length of stay for CEA during fiscal year (FY) 1996 was 5.84 days (N = 41), compared with 1.79 for a benchmark facility. OBJECTIVE: Create a critical pathway to standardize care, maintain/improve patient outcomes, reduce lengths of stay, and decrease costs. METHODS: A multidisciplinary team was formed to evaluate four patient-flow options. The team decided to discharge patients directly from the intensive care unit to meet both patient and staff needs. RESULTS: The geometric mean length of stay decreased to 1.70 days (N = 54) in FY 1998, compared with 2.42 days (N = 40) in FY 1997. The cost savings ws $5,841 per case, compared with $1,684 before creation of the pathway. This represents an annual savings of more than $224,000 and a 30% reduction in length of stay. CONCLUSIONS: The CEA pathway has standardized the care received by this group of patients. By decreasing variation, processes have become routine and more efficient.
Aged↗
Role of a critical pathway for door-to-CT-completion interval in the management of acute ischemic stroke patients in the emergency room.
OBJECTIVE: Door-to-CT-completion interval (DCI) for acute ischemic stroke patients is one of the clinical indicators of quality assurance in an emergency room (ER). The aim was to clarify whether the critical pathway improves the DCI for acute stroke patients in the ER. METHODS: The pathway describes each step in patient evaluation in sequence from the patient's arrival in the ER until the brain CT is completed. Whether to use the pathway when evaluating individual patients is left to the discretion of the physician. After excluding 8 cases with insufficient data, 52 cases diagnosed with acute stroke (29 males, 69.9 +/- 12.4 y/o) in the ER between January and February 2003 were retrospectively identified. A logistic regression analysis was used to assess the impact of application of the pathway on achievement of an acceptable DCI (<25 min). RESULTS: The pathway was applied in 21.2% of the cases included in the study, and the median DCI was reduced from 48 minutes to 22 minutes as a result (P=0.02). Comparing them with the DCI, the probability values for ambulance use, consciousness disturbance, history of stroke, and application of the pathway in univariate analyses were less than 0.10. These variables were entered into the logistic analysis, which that indicated application of the pathway was the strongest variable related to acceptable DCI (OR: 10.92, 95% CI: 1.22 to 97.96). CONCLUSION: Application of the pathway was associated with an improvement of the DCI. Use of the pathway will improve the quality of the process of care in the ER.
Acute Disease↗
The role of a nurse case manager in implementing a critical pathway for infrainguinal bypass surgery.
BACKGROUND: A previous study showed the effectiveness of a clinical pathway for infrainguinal bypass surgery in reducing postoperative length of stay (LOS) in an acute care setting. Most of the deviations from the pathway were due to patient factors (50%) and/or external disposition problems (30%), but 20% were related to physician or system problems that could potentially be modified. The current study examined those factors influencing LOS following infrainguinal bypass surgery and the impact of daily rounds by a nurse case manager--a vascular nurse specialist--on LOS and pathway deviations. METHODS: Data were collected through detailed chart review and prospective tracking of pathway deviations. LOS was compared in 58 patients on the modified pathway (with the nurse case manager) to 69 patients on the original pathway and 67 prepathway controls. Multivariate analysis was used to identify factors influencing postoperative LOS and to compare LOS among the three groups. RESULTS: Use of a nurse case manager significantly reduced physician-related deviations, from the pathway from 10% to 0% (p = .015), and reduced system-related deviations from 3% to 0%. Median postoperative LOS was 7 days before the pathway was begun, 6 days with the original pathway, and 5 days after the introduction of a vascular nurse specialist (p = .0001). There were no differences in rates of complications, rates of readmission, or mortality. CONCLUSIONS: Intervention by a nurse case manager facilitated implementation of a critical pathway for patients undergoing infrainguinal bypass surgery, especially by preventing patient deviations due to intrainstitutional factors.
Aged↗