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PubMedDate not supplied

Using the Liverpool Care Pathway for a dying patient.

This article describes the experience of staff in one acute hospital in Northern Ireland who adapted the Liverpool Care Pathway (LCP) for the dying patient to suit their organisation. It focuses on one patient's journey, from diagnosis to terminal care. The patient remained on the care pathway for 12 days. This reflection demonstrates that, as long as patients continue to meet the criteria for the LCP, some may be on the care pathway for more than the recognised average of two days.

Adenocarcinoma↗
PubMedDate not supplied

The care pathway: a tool to enhance clinical governance.

A care pathway defines in detail the individual components of treatment for a group of patients. A well-written pathway can lead to consistent care of the highest quality. There are both educational and audit advantages to the approach. The authors detail the means by which groups are selected and the care pathways written. An example of the benefits that can accrue comes from their experience at Ashford Hospital of running a pathway for patients having prostate surgery. The pathways are appreciated by patients, nurses, doctors and managers. Care is improved, costs contained and clinical governance enhanced.

Critical Pathways↗
PubMedDate not supplied

Inpatient asthma clinical pathways for the pediatric patient: an integrative review of the literature.

BACKGROUND: Asthma is one of the most prevalent childhood chronic illnesses in the United States leading to nearly 190,000 pediatric hospitalizations yearly. In response to the increasing number of children with asthma being hospitalized, some institutions have developed and implemented clinical pathways and are now reporting their findings in the literature. The purpose of this paper was to conduct an integrative literature review of studies using an inpatient clinical pathway for the management of pediatric asthma. METHOD: Five research-based articles evaluating clinical pathways for the management of inpatient pediatric asthma were included in this review. The integrative review was conducted using the guidelines set forth by Ganong (1987). RESULTS: The results revealed that clinical pathways appear to be effective in reducing length of stay and hospital costs associated with inpatient pediatric asthma. The pathways were not as effective in reducing readmission rates or affecting clinical outcomes for patients such as increasing asthma education, the use of controller medications, spacers, and peak flow meters. PRACTICE IMPLICATIONS: Although the pathways are effective in reducing hospitalization costs associated with asthma, there was little reported improvement in clinical outcomes. Nurses should ensure that each pediatric asthma hospitalization provides an opportunity to promote education about asthma. This approach may lead to decreased asthma admissions and increased self and family management of pediatric asthma. Future research should focus on the clinical outcomes of patients using the inpatient pathways and also on the development of pathways to be used in outpatient settings that manage pediatric asthma.

Asthma↗
PubMed2004

Development of a clinical pathways analysis system with adaptive Bayesian nets and data mining techniques.

The use and development of software in the medical field offers tremendous opportunities for making health care delivery more efficient, more effective, and less error-prone. We discuss and explore the use of clinical pathways analysis with Adaptive Bayesian Networks and Data Mining Techniques to perform such analyses. The computation of "lift" (a measure of completed pathways improvement potential) leads us to optimism regarding the potential for this approach.

Bayes Theorem↗
PubMedDate not supplied

Clinical pathway for pneumonia: development, implementation, and initial experience.

BACKGROUND: As part of a large multidisciplinary project to reduce cost, decrease hospital length of stay, and improve efficiency of patient care at Saint Mary's Hospital, a clinical pathway for pneumonia was developed and implemented. METHODS: After using analysis of severity-adjusted data to determine which conditions would be best targets for improvement, a utilization management steering committee created a multidisciplinary group to develop a clinical pathway for pneumonia. This group was led by physician champions and consisted of representatives from nursing, respiratory therapy, pharmacy, and home healthcare. With information gained from chart abstraction, which identified "best practice" patterns, guidance from the medical literature, and local expertise, this group developed a clinical pathway that included an auxiliary protocol for respiratory care and a detailed educational brochure for patients. Before implementing the clinical pathway, extensive educational activities were undertaken involving the medical staff, house staff, nurses, and other staff. Data collected on consecutive patients discharged after implementation of the pathway were compared with data collected on patients discharged before the pathway in 1994. RESULTS: For DRG 89, the patients who were on the pathway in comparison to the control patients from 1994 had a lower average length of stay by 1.45 days (5.84 vs. 7.29 days) and a lower average total charge by $1,453 ($9,511 vs. $10,964). For DRG 90, the patients who were on the pathway in comparison to the control patients from 1994 had a lower average length of stay by 1.83 days (3.45 vs. 5.28 days) and a lower average total charge by $1319 ($5450 vs. $6769). CONCLUSIONS: The pneumonia clinical pathway that was implemented was associated with reductions in the length of stay and total charges. These reductions were seen in relationship to historical controls and to patients cared for concurrently who were not placed on the pathway. Although not fully used on all pneumonia patients, the presence of the pathway probably had some positive effects even on patients not formally on the pathway, through systems changes and educational influences. The pathway also positively influenced other conditions by the use of ancillary algorithms for conditions other than pneumonia, and the more rapid administration of antibiotics for other infectious diseases. Also, lessons learned in the creation of this first pathway have been helpful in streamlining the process of future pathway development.

Connecticut↗
PubMedDate not supplied

Determining the cost of care through clinical pathways.

Using the steps from the first approach, the costing of clinical pathways is useful to both the clinical and administrative teams. With knowledge of pathway cost, clinicians can plan cost-effective changes in the pathway or consider cost factors when deliberating on different approaches to care. Using the patient classification system to unbundle the nursing component and using the number of nursing hours per day of care provides an opportunity to describe the intensity of the pathway in its entirety, and by each day of care. One is provided with an opportunity to learn from the cost variances by reviewing the standardized costs for the pathway, and the actual cost of care of patients on the pathway provides an opportunity to learn from the cost variances. This learning, coupled with the clinical variance analysis, can suggest new opportunities for improving care and potential cost savings. Lastly, the cost associated with a pathway is useful knowledge in negotiating managed care contracts.$

Acute Disease↗
PubMed2003

The polyglutamine neurodegenerative protein ataxin-3 binds polyubiquitylated proteins and has ubiquitin protease activity.

The ubiquitin-proteasome pathway is critically involved in the pathology of neurodegenerative diseases characterized by protein misfolding and aggregation. Data in the present study suggest that the polyglutamine neurodegenerative disease protein, ataxin-3 (AT3), functions in the ubiquitin-proteasome pathway. AT3 contains an ubiquitin interaction motif (UIM) domain that binds polyubiquitylated proteins with a strong preference for chains containing four or more ubiquitins. Mutating the conserved leucine in the first UIM (L229A) almost totally eliminates binding to polyubiquitin chains while a similar mutation in the second UIM (L249A) also inhibits binding to polyubiquitin chains but to a lesser extent. Both wild-type and pathological AT3 increase cellular levels of a short-lived GFP that is degraded by the ubiquitin-proteasome pathway. AT3 has several properties characteristic of ubiquitin proteases including decreasing polyubiquitylation of 125I-lysozyme by removing ubiquitin from polyubiquitin chains, cleaving a ubiquitin protease substrate, and binding the specific ubiquitin protease inhibitor, ubiquitin-aldehyde. Mutating the predicted catalytic cysteine in AT3 inhibits each of these ubiquitin protease activities. The ability to bind and cleave ubiquitylated proteins is consistent with AT3 playing a role in the ubiquitin-proteasome system. This raises the possibility that pathological AT3, which tends to misfold and aggregate, may be exposed to aggregate-prone misfolded/denatured proteins as part of its normal function.

Animals↗
PubMed2006

Targeting downstream effectors of epidermal growth factor receptor/HER2 in breast cancer with either farnesyltransferase inhibitors or mTOR antagonists.

In breast cancer, there is an increasing recognition of the pivotal role played by the epidermal growth factor receptor (EGFR) and HER2 together with the various downstream signal transduction pathways, in particular the Ras/Raf/Mek/erk1/2 pathway that regulates cell proliferation together with the phosphatidylinositol-3-OH kinase (PI3K)/Akt/mTOR pathway that is implicated in cell survival. While monoclonal antibodies and small molecule tyrosine kinase inhibitors targeted against EGFR/HER2 are now being used for breast cancer therapy, there is considerable interest in also targeting the critical downstream pathways that cells may remain dependent upon. Activation of these downstream pathways in breast cancer may be associated with resistance to either conventional endocrine or cytotoxic therapies or, indeed, lack of response to EGFR/HER2-targeted approaches. Farnesyltransferase inhibitors (FTIs) were initially developed to target Ras activation, although their mechanism of action may be more nonspecific. Trials in breast cancer have been completed with FTIs alone or in combination with endocrine or cytotoxic therapy. Activation of the PI3K/Akt pathway has also been associated with resistance to either tamoxifen or estrogen deprivation, and preclinical studies have shown that the mTOR antagonists can restore endocrine sensitivity in breast cancer cells. Randomized phase II/III trials of aromatase inhibitors combined with mTOR antagonists are in progress and have been powered to detect whether combined therapy can significantly prolong time to disease progression compared to endocrine therapy alone. Finally, preclinical experiments are now investigating whether downstream agents should be combined with upstream EGFR/HER2 therapies to produce maximal blockade of vertical signal transduction pathways. Subsequent trials will be needed to see whether combinations of novel STIs are well tolerated and how they may further enhance clinical benefit in breast cancer.

Antineoplastic Agents↗
PubMed2002

Human cells bearing homozygous mutations in the DNA mismatch repair genes hMLH1 or hMSH2 are fully proficient in transcription-coupled nucleotide excision repair.

The transcription-coupled nucleotide excision repair (TCNER) pathway maintains genomic stability by rapidly eliminating helix-distorting DNA adducts, such as UV-induced cyclobutane pyrimidine dimers (CPDs), specifically from the transcribed strands of active genes. DNA mismatch repair (MMR) constitutes yet another critical antimutagenic pathway that removes mispaired bases generated during semiconservative replication. It was previously reported that the human colon adenocarcinoma strains HCT116 and LoVo (bearing homozygous mutations in the MMR genes hMLH1 and hMSH2, respectively), besides manifesting hallmark phenotypes associated with defective DNA mismatch correction, are also completely deficient in TCNER of UV-induced CPDs. This revealed a direct mechanistic link between MMR and TCNER in human cells, although subsequent studies have either supported, or argued against, the validity of this important notion. Here, the ligation-mediated polymerase chain reaction was used to show at nucleotide resolution that MMR-deficient HCT116 and LoVo retain the ability to excise UV-induced CPDs much more rapidly from the transcribed vs the nontranscribed strands of active genes. Moreover, relative to DNA repair-proficient counterparts, MMR-deficient cells were not more sensitive to the cytotoxic effects of UV, and displayed equal ability to recover mRNA synthesis following UV challenge. These results conclusively demonstrate that hMLH1- and hMSH2-deficient human colon adenocarcinoma cells are fully proficient in TCNER.

Adaptor Proteins, Signal Transducing↗
PubMed2001

A clinical pathway for congestive heart failure.

This study has shown improved outcomes with the use of a clinical pathway. However, under PPS additional ways for coordination among healthcare providers and patients need to be developed to ensure improved care beyond those focusing on the use of the pathway. One recommendation is the use of telehealth.

Aged↗
PubMed1997

Code Stroke: rapid transport, triage and treatment using rt-PA therapy. The NINDS rt-PA Stroke Study Group.

With the approval of rt-PA therapy for ischemic stroke, stroke care has acutely transitioned from focusing on rehabilitative services to emergency services. This treatment, which must be initiated within the first three hours after the onset of stroke symptoms, requires reorganization of current management approaches. Developing a Code Stroke Team facilitates this process and helps to identify potential thrombolysis candidates. A pathway to deliver rapid care begins with 911 notification and transport, emergency department triage and procedures, and moves through the initiation of thrombolytic therapy. We call this pathway "Code Stroke".

Cerebrovascular Disorders↗
PubMedDate not supplied

Barriers to successful implementation of a clinical pathway for CHF.

Clinical pathways represent a strategy for responding to the current healthcare environment with a focus on managing care, reducing costs, increasing patient satisfaction, and improving quality. However, many healthcare organizations have found that implementing clinical pathways is not entirely successful even when they are based on sound evidence. The purpose of this case study was to describe and explain factors related to the success or failure of implementing a clinical pathway for congestive heart failure (CHF) patients in a 300-bed community hospital. The key factors involved in the nonadoption of the CHF pathway were inconsistencies in procedures and the work group culture.

Attitude of Health Personnel↗
PubMed2003

Tackling undernutrition through appropriate supplement prescribing.

Undernutrition has significant implications for patients' clinical condition and economical consequences for the NHS. However, due to continually increasing prescribing costs for sip feeds, treating undernutrition is often seen as very costly. An audit project in Lothian was undertaken to look at the appropriateness of sip feeds being prescribed. The project found there was a significant level of inappropriate prescribing with 30% of patients having their prescriptions for supplements stopped as they were deemed unnecessary. In view of this, the community dietitians involved developed and introduced a nutritional care pathway to allow a systematic and evidence-based approach to the identification and treatment of undernutrition.

Adolescent↗
PubMedDate not supplied

Integrated care pathways: an audit tool in paediatric oncology.

The families of children undergoing treatment for cancer encounter many professionals with varying levels of training, experience and competency. This can lead to variance in the care and advice they receive. The aim of the audit described in this article was to improve care for children with fever and neutropenia by introducing an integrated care pathway. Guidelines for neutropenia were examined and a retrospective analysis of notes undertaken to study what was happening before a pathway was introduced. From this, standards were set and a pathway developed which was introduced to all members of the oncology unit and implemented as part of the children's care. This article will also focus on the audit and evaluation of the pathway. Following this, the pathway has been changed to reflect care and can now be used to introduce new evidence or research in this field.

Child↗
PubMedDate not supplied

Pathways for continence care: the validation process.

This article is the third in a series of three describing a collaborative project between continence advisers in Loddon NHS Trust, Basingstoke, East Wiltshire Healthcare Trust, Swindon, and Salisbury Healthcare Trust to develop and implement care pathways to improve continence care provided to patients. The first article described the issues facing the continence advisers and the background to the decision to develop evidence-based care pathways (Vol 9(9): 590-6). The second covered the literature search and described how each pathway evolved (Vol (17): 1165-72). This article outlines the mechanisms by which the care pathways were subjected to a process of content validation.

Attitude of Health Personnel↗
PubMed2006

Direct admission to cardiology for patients hospitalized for atrial fibrillation reduces length of stay and increases guideline adherence.

OBJECTIVE: We hypothesized that a clinical pathway for inpatient management of atrial fibrillation on a cardiology service would result in improved resource utilization. METHODS: In July 2002, an evidence-based pathway was developed for treatment of patients hospitalized for atrial fibrillation. Guidelines directed patient care from admission from the emergency department to inpatient management on a cardiology service. Ancillary testing, anticoagulation, and inpatient length of stay were then compared before and after institution of the pathway. RESULTS: The overall length of stay was significantly shorter for patients admitted through the pathway (43.0 hours vs. 82.0 hours, p < 0.01). After the pathway, there was increased use of transesophageal echocardiography and a trend toward increased use of warfarin. CONCLUSIONS: Patients requiring hospitalization for symptomatic atrial fibrillation had a nearly 50% reduction in length of stay, with a trend toward increased utilization of risk-appropriate antithrombotic therapy, if they were directly admitted through cardiology via a clinical pathway.

Aged↗
PubMed1997

Lumbar discectomy path emphasizes pain control.

Case managers at University of Pittsburgh Medical Center have cut costs by $1,000 per case and reduced length of stay (LOS) from 4.92 days to just under two days for patients with lumbar discectomy by taking an aggressive approach to pain management. Case managers also found that patients' expectations helped drive up LOS. They prepare patients for early discharge by giving them an easy-to-read patient pathway that details the process of care. The lumbar discectomy pathway also emphasizes postoperative ambulation over bed rest, and reduces the number of individual blood tests required prior to surgery.

Case Management↗