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PubMed1998

The development and implementation of normal vaginal delivery clinical pathways in a large multihospital health system.

The entire country has become more concerned with healthcare costs due to managed care, capitation risk-based contracts, and the near elimination of the cost-plus reimbursement system. Clinical pathways have become one way to reduce unnecessary resource consumption by reducing provider variance, improving clinical outcomes, and reducing cost. We present here our rationale and process for developing a common clinical pathway for normal vaginal delivery in a large and varied multihospital system. We also discuss how this new pathway is expected to improve quality of care and reduce costs.

Critical Pathways↗
PubMed1999

Evidence-based practice for nurse practitioners with clinical pathways.

Evidence-based practice is essential for clinical excellence for nurse practitioners (NPs). Client outcomes must be measured and clearly linked to measurable nursing interventions. To ensure evidence-based practice, clinical pathways can be used as a vehicle to implement care. Clinical pathways track outcomes and interventions, and provide a means for accurate documentation. This article discusses evidence-based practice and the use of clinical pathways by psychiatric NPs in two settings: home care and an outpatient psychiatric clinic.

Ambulatory Care↗
PubMed2000

What to do until the POEMs arrive. An endothelial example.

There is a growing trend toward evidence-based medicine, in which patient-oriented data are valued more highly than disease-oriented evidence (DOEs). In the vernacular of evidence-based medicine, the old DOEs are slowly being replaced by POEMs (patient-oriented evidence that matters). Unfortunately, POEMs do not yet exist to meet every family-practice need. When there are no POEMs to determine an appropriate therapeutic choice, another decision-making method must be used. This method includes liberal use of DOEs combined with thoughtful use of causal pathways to provide preliminary direction. This article applies that method to an example from the growing basic science surrounding endothelial functioning.

Critical Pathways↗
PubMed1998

Impact of early tracheal extubation on hospital discharge.

Economic realities of the continuing increased utilization of cardiac surgery in the 1990s have led to the practice of early tracheal extubation and shortening of the length of intensive care unit and hospital stays. In this era of cost-containment and physician report cards, we are held accountable for patients' outcome in terms of mortality, morbidity, quality of life, length of stay, and cost of care. This report outlines the factors that influence costs of cardiac surgery. These include patient risk, anesthesia, surgical, intensive care unit, and health care systems or hospital factors. The current literature on outcome, utilization, and cost implications of early tracheal extubation in cardiac surgery is summarized and discussed. It has been demonstrated that early extubation anesthesia is safe and cost-effective and can improve resource utilization in cardiac surgery, but to achieve a maximum cost benefit from fast-track or early extubation anesthesia in cardiac patients, team organization of a fast-track cardiac surgery program must be implemented. A perioperative clinical pathway management in fast-track cardiac surgery is presented.

Anesthesia, General↗
PubMed2001

Role of the oncogenic Raf-1 in orchestration of discrete nuclear factor-kappaB-activating pathways.

Raf-1, a key kinase in the Ras signaling pathway, plays critical roles in cell differentiation, proliferation, and tumorigenesis. However, knowledge of the Raf-1 in inflammation is limited. Using an inducible oncogenic Raf-1, we show that the Raf-1 orchestrates the discrete NF-kappaB activating pathways. While the Raf-1 activation induces a modest IkappaB degradation by enhancing the basal IkappaB kinase activity, it contradictorily suppresses the proinflammatory cytokine inducible IkappaB kinase complex, leading to an inhibition of TNF-alpha- and IL-1beta-induced NF-kappaB activation. Despite considerable degrees of overlap, LPS signaling is not affected by Raf-1. By either conditionally reducing Raf-1 activity or completely disrupting the Raf-1 signaling by PD98059, a specific inhibitor of MEK1, the otherwise inhibited cytokine responses can be restored. Moreover, when the activity of Raf-1 is up-regulated during the cell cycle progression from the G(0) phase to the late G(1) phase, the enhanced Raf-1 activity suffices to shift the TNF-alpha response from the sensitive to the insensitive state. Together, these studies elucidate a mechanism by which signaling outputs are shaped by the intracellular Raf-1, thus explaining the "cellular context"-dependent cytokine response.

Animals↗
PubMed2006

Metastasis tumor antigen family proteins during breast cancer progression and metastasis in a reliable mouse model for human breast cancer.

PURPOSE: Chromatin remodeling pathways are critical in the regulation of cancer-related genes and are currently being explored as potential targets for therapeutic intervention. The metastasis tumor antigen (MTA) family of proteins, MTA1, MTA2, and MTA3, are components of chromatin remodeling pathways with potential roles in breast cancer. Although all three MTA family proteins have been shown to be associated with metastatic progression of breast cancers, the expression characteristic of MTA1-3 proteins in a multistep breast cancer progression model remains unknown. Structural and functional studies have suggested that they are heterogeneous in the Mi-2/NuRD complex, exhibit tissue-specific patterns of expression, and impart unique properties to estrogen receptor-alpha (ERalpha) action. This led us to hypothesize that each member of the MTA family possesses a unique role and interacts with different pathways in the stepwise process of breast cancer development and progression. EXPERIMENTAL DESIGN: MTA family proteins were examined by immunohistochemistry in breast cancer processes ranging from normal duct, to premalignant lesions, to invasive carcinoma, and to metastasized tumors in PyV-mT transgenic mice, which represents a reliable model for multistage tumorigenesis of human breast cancer. We also determined the association of MTA proteins with the status of cell proliferation, ER, E-cadherin and cytoplasmic beta-catenin, and cancer-related coactivators, AIB1 and PELP1. RESULTS: The expression of all three MTA proteins was altered in primary breast tumors. Each MTA protein had a unique expression pattern during the primary breast tumor progression. Altered expression of MTA1 was observed in both premalignant lesion and malignant carcinoma, but an elevated nuclear expression was observed in ER-negative carcinomas. MTA3 was exclusively expressed in a subset of cells of ER-positive premalignant lesions but not in carcinomas. MTA2 expression seems to be unrelated to ER status. Loss of MTA3 expression and more nuclear localization of MTA1 occurred with loss of E-cadherin and decreased cytoplasmic beta-catenin, two molecules essential for epithelial cell adhesion and important tumor cell invasion. At the late stage of tumor formation, MTA1 is usually expressed in the center of tumors. Coincidentally, the distribution of MTA1-positive cells at this stage was complementary to that of AIB1 and PELP1, which were localized to the tumor periphery with relatively active cell proliferation, scattered ER-positive cells and a limited differentiation. In metastasized lung tumors, the expression pattern of MTA-protein expression was distinct from that in primary counterparts. CONCLUSIONS: The findings presented here support the notion that each member of the MTA family might potentially play a stepwise role in a cell type-specific manner during breast cancer progression to metastasis. On the basis of the noted temporal expression patterns of MTA proteins with ER status, cell adhesion-essential regulators (E-cadherin and cytoplasmic beta-catenin), and coactivators, we propose that MTA protein-related chromatin remodeling pathways interact with steroid receptors, growth factor receptors, and other transcriptional signaling pathways to orchestrate the governing of events in breast cancer progression and metastasis.

Animals↗
PubMed2003

Dual modes of endoplasmic reticulum-to-Golgi transport in dendrites revealed by live-cell imaging.

Organelles of the neuronal secretory pathway are critical for the addition of membrane that accompanies neuronal development, as well as for the proper localization of plasma membrane proteins necessary for polarity, synaptic transmission, and plasticity. Here, we demonstrate that two organizations of the secretory pathway exist in neurons: one requiring processing of membrane and lipids in the Golgi complex of the cell body and one in which endoplasmic reticulum (ER)-to-Golgi trafficking is localized to dendrites. Using time-lapse imaging of green fluorescent protein-tagged cargo proteins and compartment markers, we show that organelles of the secretory pathway, including ER, ER exit sites, and Golgi, are present and engage in trafficking in neuronal dendrites. We find that ER-to-Golgi trafficking involves highly mobile vesicular carriers that traffic in both the anterograde and retrograde directions throughout the dendritic arbor. Dendritic Golgi outposts, which appear developmentally during the phase of process outgrowth, are involved in the trafficking of both integral membrane proteins and the secreted neuronal growth factor BDNF. This distributed dendritic Golgi represents an organization of the secretory pathway unique among mammalian cells.

Animals↗
PubMedDate not supplied

2,3,7,8-Tetrachlorodibenzo-p-dioxin activates ERK and p38 mitogen-activated protein kinases in RAW 264.7 cells.

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) is a widespread environmental contaminant, exposure to it eliciting a broad spectrum of deleterious pathophysiological effects. Since mitogen-activated protein kinase (MAPK) pathways appear to play an important role in both cell survival and the apoptotic process, we assessed the effects of TCDD on the activation of extracellular signal-regulated kinase (ERK), Jun-N-terminal kinase (JNK), p38 MAPKs and caspase-3 in RAW 264.7 cells. TCDD treatment induced a transient upshift in ERK activity, followed by a decline, but a concomitant dramatic activation of p38. However, TCDD did not cause any apparent change in the activity of JNK, though it induced an up-regulation in caspase-3 activity. These results demonstrate that the equilibrium between the ERK and p38 pathways is critical to the fate of the cells, and that the activation of p38, upstream of caspase, plays an important role in the apoptotic process. The data obtained in this study also suggests that TCDD activates the MAPK pathway via an arylhydrocarbon receptor (AhR)-independent mechanism in RAW 264.7 murine macrophages.

Animals↗
PubMed2006

IL-13 and epidermal growth factor receptor have critical but distinct roles in epithelial cell mucin production.

Overproduction of mucus is a central feature of asthma. The cytokine, IL-13, epidermal growth factor receptor (EGFR), and transcription factor, FOXA2, have each been implicated in mucus production, but the mechanistic relationships between these molecules are not yet well understood. To address this, we established a primary normal human bronchial epithelial cell culture system with IL-13-induced mucus production and gene transcript expression changes similar to those seen in vivo in mice. IL-13 did not stimulate release of the EGFR ligand, transforming growth factor (TGF)-alpha. However, there was constitutive release of TGF-alpha from normal human bronchial epithelial cells, and inhibition of TGF-alpha or EGFR reduced both constitutive and IL-13-induced mucin production. Microarray analysis revealed that IL-13 and the EGFR pathway appear to have almost completely independent effects on transcript expression. IL-13 induced a relatively small set of transcripts, including several novel transcripts that might play a role in pathogenesis of allergic airway disease. In contrast, EGFR activity had extensive effects, including altered expression of many transcripts associated with cell metabolism, survival, transcription, and differentiation. One of the few common effects of IL-13 and EGFR signaling was decreased expression of FOXA2, which is known to prevent mucus production. We conclude that the IL-13 and EGFR pathways make critical but quite distinct contributions to gene regulation in airway epithelial cells, and that both pathways affect expression of the key transcription factor, FOXA2, a known regulator of mucus production.

Administration, Intranasal↗
PubMed2001

The impact of a clinical pathway for gastric bypass surgery on resource utilization.

BACKGROUND: Clinical pathways are believed to improve patient care and reduce costs. Our hypothesis was that a gastric bypass pathway would decrease hospital resource utilization and cost of care without adversely affecting patient care. METHODS: The prepathway (Pre) group consisted of 16 gastric bypasses (6/98 to 3/99). The postpathway (Post) group includes 12 gastric bypass procedures performed after institution of the clinical pathway (4/99 to 12/99). The impact of the clinical pathway on hospital length of stay (LOS) and resource utilization was investigated. A comparison of costs was performed using cost/charge ratios. Hospital readmissions and postoperative complications were also examined. RESULTS: Despite increased obesity/medical acuity of the Post group, hospital LOS decreased by 3 days (P < 0.0001). Total hospital costs decreased by over $1600/case (>15%). Postpathway savings were greatest for room and board (34%), supplies (41%), and lab/radiology costs (50%). An increase in OR costs (22%) was observed in the Post group. This was due to an increase in anesthesia time (epidural catheter placement) and equipment costs (ultrasonic shears). Despite reductions in hospital LOS and resource utilization, the complication rate (Pre 12%, Post 16%) was similar and two patients in each group required brief readmission. CONCLUSIONS: A pathway for gastric bypass decreased hospital LOS and resource utilization. OR-related expenses account for 34-50% of total costs and must be monitored closely for surgical patients. The reduction in costs observed with this clinical pathway was not associated with an increase in postoperative complications or hospital readmission.

Adult↗
PubMed2001

Clinical pathway for impalpable or small lung lesions treated with coil marking and thoracoscopy.

OBJECTIVES: Advances in computed tomography are detecting increasingly impalpable or small pulmonary lesions. We propose a clinical pathway for managing such lesions. METHODS: We conducted a retrospective study in a community teaching hospital to describe the hospital schedules of 18 patients having 19 lesions 10 mm or less and ground glass attenuation. Under computed tomography, a coil (Complex Helical Fibered Platinum Coil-18) was placed at the proximal side of the lesion. Using thoracoscopy and radiographic fluorography, we conducted partial lung resection targeting the coil the next day, adding lobectomy, if required. RESULTS: Final diagnosis included primary and metastatic lung cancer (n = 14), atypical adenomatous hyperplasia (n = 1), and benignancy (n = 4). Patients were admitted 2* days before surgery (*Numbers are medians). On postoperative day 3, chest tubes were removed. Epidural analgesia was continued for 5 days. On postoperative day 7, patients were discharged. Their admission charge was a total of yen 979,610. CONCLUSIONS: The hospital course above may be applied to the clinical pathway for managing impalpable or small lung lesions.

Adenocarcinoma, Bronchiolo-Alveolar↗
PubMed1999

Patient perceived quality-of-care in hospital in the context of clinical pathways: development of an approach.

Clinical pathways have been introduced in many hospitals with the aims of improving efficiency, reducing costs, and improving the quality and outcomes of care. However, there is a shortage of research evidence regarding the extent to which they do in fact achieve such aims. This paper describes the development and testing of a patient-perceived quality-of-care questionnaire for use in relation to the assessment of clinical pathways. Issues of validity and reliability are addressed and illustrative examples of results for two pilot hospitals are presented.

Adult↗
PubMed1995

Patient-focused care and its role in hospital process re-engineering. Describes a programme of change implemented at the Derbyshire Royal Infirmary.

Examines the concept of patient-focused care and how it fits into hospital process re-engineering. Describes the project undertaken at the Derbyshire Royal Infirmary, to implement patient-focused care and care pathway development in accident and emergency, and trauma and orthopaedics. Concludes with an insight into how care pathways have been used to improve hospital documentation, reduce duplication of information and provide a rich source of data for effective clinical audit.

Critical Pathways↗
PubMed2006

A decade on: has the use of integrated care pathways made a difference in Lanarkshire?

This article aimed to: (1) review the work carried out in Lanarkshire between 1996 and 1999 on a Scottish Executive funded project and (2) to discuss the situation from 1999 to 2006. (1) This 3-year project led to the successful development and implementation of over 100 integrated care pathways in an urban teaching hospital (Glasgow) and a district general hospital (Lanarkshire) and was the first in-depth study of integrated care pathways to be undertaken in Scotland. The main report on the project was produced in 1999 (Clinical Audit and Quality using Integrated Pathways of Care) and reported increased adherence to British Thoracic Society and Scottish Intercollegiate Guidelines Network guidelines and multiple best practice statements, and improved standards of documentation. The general findings were that process indicators were improved by integrated care pathway use and there was some suggestion of improved length of stay with no apparent effect on outcome. Evidence was found that integrated care pathways have made a difference for both patients and staff. (2) This provides an update of integrated care pathway development in a changing environment within NHS Lanarkshire and examines some of the key factors for success.

Adult↗
PubMed2002

ROMEO: a rapid rule out strategy for low risk chest pain. Does it work in a UK emergency department?

AIMS: To examine the feasibility of using the ROMEO (rule out myocardial events on "obs" ward) pathway for low risk patients with chest pain in a UK emergency department. METHODS: A prospective study was undertaken to determine outcomes for the first 100 patients entering the pathway (from May to Oct 1999). Serum troponin levels, serial ECG recordings, exercise test result, total length of stay, and final diagnoses were reviewed. Patients were telephoned after discharge to inquire about persisting or recurrent pain, and further investigations after completing the ROMEO pathway. RESULTS: 82 of 100 (82%) had myocardial damage excluded by serum troponin assay. Sixty two of 82 (76%) of these completed exercise tolerance testing (ETT). Fifty seven of 62 (92%) ETTs were negative. Twenty of 82 (26%) did not undergo ETT because of mobility problems, recent ETT, or if considered very low probability of cardiac pain on consultant review. Five of 100 (5%) had an increased initial troponin and five of 100 (5%) had an increased 12 hour troponin. These patients were referred for admission under the general physicians. Seven of 100 (7%) were referred for other reasons (late ECG changes, continuing or worsening pain). One patient self discharged. Length of stay varied because of changes to arrangements for ETT. The median time for all patients over the period studied was 23 hours. All patients were discharged within an hour of a negative ETT. FOLLOW UP RESULTS: 67 of 74 (91%) eligible patients were contacted by telephone. Forty six of 67 (69%) had no further pain, attendances, or GP consultations. Six of 67 (9%) had further cardiological investigation or treatment. CONCLUSIONS: A rapid rule out strategy such as the ROMEO pathway is feasible in the UK healthcare setting and provides standardised and consistent evaluation.

Adult↗
PubMed2005

A nurse-led ambulatory care pathway for patients with deep venous thrombosis in an acute teaching hospital.

This article describes the management of deep vein thrombosis (DVT) using an ambulatory nurse-led pathway and the compression technique using duplex ultrasound. This pathway permits the management of the "walking wounded" as well as other patients at varying risks of having DVT and in so doing has changed the approach toward the management of this common clinical event. The success of the described pathway is attributed to the development of low molecular weight heparin and the reliability of diagnostics.

Ambulatory Care↗
PubMedDate not supplied

Integrated care pathway for carotid endarterectomy patients.

Modern day health care should incorporate strategies for controlling both the cost and quality of clinical interventions, to ensure that care is evidence based, outcomes are monitored and any areas of poor practice are improved. An integrated care pathway for an area of vascular surgery was devised with these issues in mind. The chosen pathway was for patients undergoing surgery to remove atheromatous plaques from the carotid artery. The evidence base for the interventions detailed in the pathway are given and potential advantages and disadvantages of utilizing care pathways offered. Utilizing this form of structured care, health professionals may be able to ensure cost containment combined with high quality patient care.

Critical Pathways↗