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The purpose of this report is to describe the design, implementation, and advantages of a clinical pathway for patients undergoing ambulatory surgery. The primary purpose of the pathway is to dovetail the preoperative, intraoperative, and postoperative care of the ambulatory surgical patient. The pathway provides a mechanism to collect data and evaluate patient outcome.
OBJECTIVES: A clinical pathway standardizing management for patients with an admission diagnosis of pneumonia was initiated after a previous study found delayed time to initial antibiotic administration, a longer length of stay, and higher mortality rate for the authors' patients as compared with those in a "benchmark" hospital. The current study was undertaken to determine whether implementation of the clinical pathway resulted in statistically significant decreases for these measures, both in the initial year following pathway implementation and two years later. METHODS: A retrospective chart review was completed for three cohorts of pneumonia patients admitted via the ED: 1) three months immediately prior to pathway implementation, 2) 10-12 months after implementation of the pathway, and 3) 34-36 months after implementation of the pathway. Four standard antibiotic regimens were used following pathway implementation: community-acquired, community-acquired penicillin-allergic, nursing home-acquired, and nursing home-acquired penicillin-allergic. Demographics, medical history, presentation signs and symptoms, process of care, and outcome data were abstracted from each patient's medical record. RESULTS: The mean time to antibiotic administration decreased from 315 minutes prepathway to approximately 175 minutes during the first postpathway period and 171 minutes at three years (ANOVA, p < 0.0001). The percentage of patients who received antibiotics in the ED increased from 58% prepathway to 94% during the first postpathway period and 97% at three years (chi square, p < 0.0001). Length of stay decreased from 9.7 prepathway to 8.9 days during the first postpathway period and 6.4 days at three years (ANOVA, p < 0.0001). There was no significant change of in-hospital mortality (9.6% prepathway to 5.2% and 4.9%) in the two respective periods. CONCLUSIONS: This study demonstrates that implementation of a pneumonia clinical pathway for the management of hospitalized patients admitted via the ED decreases the time to initial antibiotic treatment and increases the proportion of patients initially treated with antibiotics in the ED. These effects were evident in the first year following pathway implementation and sustained at the three-year study interval.
STUDY OBJECTIVES: To describe our 5-year experience with a clinical pathway used to ensure the timely communication and evaluation of unsuspected radiologic findings (URFs) noted on clinically requested chest imaging. DESIGN: Prospective data collection on clinical practice. SETTING: Academically affiliated Veterans Affairs medical center. PARTICIPANTS: Pulmonary physicians, nurses, and radiologists. RESULTS: Over a period of 5 years, 1,629 URFs were referred to the pathway (from chest radiographs, 1,359 [83.4%]; from CT scans, 270 [16.6%]). Most URFs (78%) were nodules, with a specific diagnosis made in one third of URFs, and with a specific diagnosis thought to be clinically significant in another one third of URFs. The most common diagnosis was neoplasm, with over two thirds of these diagnoses being lung cancer. One third of lung cancers detected were either stage 1 or 2, with 1 in 17 of all URFs being stage IA lung cancer. The cost of the pathway was estimated at 28,600 dollars per year. CONCLUSIONS: URFs noted on chest imaging are frequently clinically significant, and a systematic approach to managing URFs, such as a clinical pathway, can significantly improve care in a large teaching hospital.
Practice guidelines and clinical pathways are increasingly being used as tools to enhance the quality of health care services and to manage costs better. This article reviews the role of guidelines and clinical pathways in health care as defined within the broader concept of practice policies. The factors that increase the effectiveness of practice policies are examined. These include the origin of development, dissemination technique, and implementation strategy. Policies that are internally developed and implemented with concurrent reminder systems are the most effective. Clinical pathways fit these criteria and are therefore highly effective policy types. The roles that pharmacists within health systems can undertake in policy development are described. These include writing the policy document, providing expert review, providing education, and most important, facilitating the desired outcomes by implementing pharmacy services that promote compliance with the guidelines. Examples of pharmacy-based guideline and pathway implementation from the Henry Ford Health System are described for inpatient anticoagulation, outpatient preferred drug formulary policy, and outpatient lipid therapy management.
Clinical pathways can help nurse managers develop clinical staff, guide quality improvement, enhance interdisciplinary practice, standardize care delivery, control the budget, and increase patient satisfaction.
BACKGROUND: Clinical pathways have been developed to guide evidence-based practice in health care. The documented use of a clinical pathway by clinicians can be measured by chart audit and used effectively as part of the quality improvement process. The application of a rigorous process of collecting data for quality improvement adds further evidence to the quality improvement process. This article describes a chart audit methodology developed and implemented to measure documented compliance with a myocardial infarction clinical pathway used in an acute hospital. CONCLUSION: The results informed a quality improvement process where documented use of the clinical pathway increased from 23 per cent to 58 per cent (p = 0.000). The chart audit methodology described was a key component in this successful quality improvement initiative.
Clinical pathways have been implemented in a variety of health-care settings. They serve as a useful tool for case managers in acute care settings as well as ambulatory care settings, skilled care facilities, and long-term care facilities. The use of these tools in the perioperative setting, along with variance documentation and data feedback is presented here. By creating tangible definitions of quality in the perioperative setting, clinical pathways improve patient care and assure clinical consistency and continuity of care.
The case management program at Stanford Health Services has evolved over the past 5 years in response to the changing managed care marketplace and institutional needs. The challenge for the program has been to meet rapidly changing needs of both internal and external customers: patients, physicians, staff, and payers. The program has evolved from an inpatient model integrating discharge planning and utilization review, to include ambulatory case management in the clinic setting, management of prepaid health enrollees in the community, and clinical pathways. This article will describe the evolution of case management at Stanford and individual program components that resulted in significant savings to the organization.
The purpose of this study was to evaluate the effects of implementing a clinical pathway for transurethral resection of the prostate on hospital costs and procedures, outcomes, and complications. Consecutive patients who underwent transurethral resection of the prostate for benign prostate hyperplasia in our hospital before (February-August 1996) and after (October 1996-March 1997) implementation of the clinical pathway were included. Statistical analyses included Student's t-test to test the impact of the clinical pathway on resource consumption and medical care processes, and multiple linear regression to control for patient characteristics such as age, severity of disease, and comorbidity. The major findings of this study were that implementation of the clinical pathway 1) decreased resource consumption and controlled medical care expenditure; 2) influenced physicians' patterns of practice and decreased the number of procedures performed; and 3) did not affect clinical outcomes or complication rates. In conclusion, our results support the hypothesis that the clinical pathway is an effective medical management tool to contain costs, which does not adversely affect quality of care. We suggest health policy makers promote clinical pathways in more hospitals to encourage appropriate resource consumption.
The activation of the c-Jun N-terminal kinase (JNK) pathway is critical for naturally occurring neuronal cell death during development and may be important for the pathological neuronal cell death of neurodegenerative diseases. The small molecule inhibitor of the mixed-lineage kinase (MLK) family of kinases, CEP-1347, inhibits the activation of the JNK pathway and, consequently, the cell death in many cell culture and animal models of neuronal death. CEP-1347 has the ability not only to inhibit cell death but also to maintain the trophic status of neurons in culture. The possible importance of the JNK pathway in neurodegenerative diseases such as Alzheimer's and Parkinson's diseases provides a rationale for the use of CEP-1347 for the treatment of these diseases. CEP-1347 has the potential of not only retarding disease progression but also reversing the severity of symptoms by improving the function of surviving neurons.
BACKGROUND: Clinical pathways are a new initiative intended to reduce costs while maintaining or even improving the quality of care. Based on treatment guidelines, patient pathways display an optimal sequence of staff actions in the preoperative, operative, and postoperative in- and outpatient treatment. METHODS: In this study, patient pathways were developed for selected elective general surgical disease entities following a new modular approach. All elements of care and their direct costs to the hospital were identified. Multidisciplinary teams of physicians, nurses, and administrative staff constructed and implemented the patient pathways. RESULTS: In the 1-year pilot phase, we developed and implemented 7 pathways with 16 subpathways: open herniorrhaphy, laparoscopic cholecystectomy and fundoplication, thyroidectomy, surgical treatment of diverticulitis and colon carcinoma and kidney transplantation. CONCLUSIONS: Patient pathways combine the management of care, hospital processes, and costs in a new integrated concept. Patient pathways streamline and standardize care, facilitate communication, and contribute to cost control efforts.
Admitting patients with fractured neck of femur using fast tracking procedure is well established in over 75% of hospitals in the United Kingdom. A retrospective study on 143 patients admitted using such procedure revealed inadequacies in the system. Although the waiting time in the Accident and Emergency Department (A&E) was reduced, it did not contribute much to the other aspects of patients outcome. We conducted a prospective trial using a multidisciplinary integrated care pathway (ICP) for the management of patients with fractured neck of femur. The objective of this study was to assess the effect of this protocol on the outcome compared to the earlier findings. The outcomes measured were admission time, time to surgery, length of in-hospital stay, cancellations, and 30-day mortality. The results showed a significant reduction in the length of hospital stay (P = 0.001). The 30-day mortality (P = 0.056) and number of patients operated within 24 h of admission were better (P = 0.048) but not significant. There was no difference in the time to admission to orthopaedic ward and other related complications between the two groups. This study has shown that a multidisciplinary care pathway for management of patients with fractured neck of femur has potential benefits.
A significant proportion of pathology tests ordered in hospital are unnecessary. Specific measures targeting the increasing appropriateness of pathology service use have been shown to decrease overall ordering of laboratory tests. However, it is not clear whether general programmes to improve quality of care will have any impact on the use of pathology services. Use of pathology services was compared within two separate prospective controlled clinical trials of re-engineered clinical pathways for both elective (surgical) patients and acute unplanned (medical) admissions. Trial One was a controlled trial of a re-engineered surgical service. Booked patients in the treatment group were admitted on the day of surgery, care was guided by a clinical pathway, and patients were discharged early with domiciliary post-acute care. Controls were admitted on the day before surgery, treated according to usual practice and discharged according to surgeons' preferences. In Trial Two, acute medical patients admitted to hospital through the Emergency Department (ED) were randomised into a treatment (Hospital in the Home) or a control (inpatient) care pathway. In both studies, patients on the re-engineered clinical pathways were well matched demographically and clinically. Health outcomes and satisfaction ratings were comparable. Seventy per cent fewer laboratory tests were ordered in the elective surgery intervention group (P < 0.0001), while the treatment group of the acute medical patients had 25% fewer tests ordered (P = 0.0133). Pooled results also showed a significantly lower rate of test ordering (P < 0.001) for the treatment group (Mann-Whitney U-Wilcoxon ranked sum test). The findings of these audits of controlled, prospective trials suggested overuse of laboratory tests in New South Wales public hospitals, and that savings can be generated by using clinical pathways and applying clinical criteria to the ordering of tests without adversely affecting health outcomes.
Appendicitis is a frequent pediatric surgical condition for which there is great variability among practitioners regarding diagnosis and postoperative management. With this in mind, the authors designed and implemented an evidence-based appendicitis clinical pathway at their institution. Establishment of the pathway resulted in decreased hospital cost, reduced hospital stay, and fewer unnecessary laboratory tests. The purpose of the current study was to determine the sustainability of the pathway beyond its initial implementation phase. The authors showed that several, but not all, favorable outcomes of the pathway were sustained. These data suggest that a clinical pathway for appendicitis at the authors' institution results in sustained beneficial effects in some but not all outcome parameters. Ongoing monitoring of pathway compliance, continued education of practitioners and nursing personnel, and identification of key pathway team member(s) responsible for the pathway system might result in a greater long-term impact of these guidelines.
Clinical pathways are processes of care that use a multidisciplinary team effort to move patients toward a designed outcome. This article details the challenges of a Quality Enhancement and Clinical Resource Management Team in designing and implementing a successful congestive heart failure pathway at a teaching hospital. Academic institutions have the resources as part of their research mission, to enhance the development of clinical pathways and assess their outcomes.
STUDY OBJECTIVE: To establish the effects of the use of a clinical pathway that includes a minimally invasive access among patients undergoing pneumonectomy. DESIGN: Prospective study from February to December of 1997. SETTING: A community hospital. PATIENTS: Five consecutive patients with a mean age of 60 years (range 43 to 74 years) with lung malignancies who required pneumonectomy. INTERVENTIONS: Clinical pathway based on patient education, a meticulous minimally invasive operation (oblique muscle-sparing minithoracotomy), intercostal nerve cryoanalgesia, and a quick postoperative resumption of physical activity. RESULTS: All five patients were extubated in the operating room. They all had unrestricted shoulder mobility in the recovery room, and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation, and one patient was able to ambulate freely only a few hours after the procedure. Four patients were discharged the day after surgery, and one patient was discharged the same day of the operation. None required readmission related to the procedure. CONCLUSION: This initial experience seems to indicate that the application of this clinical pathway in patients undergoing pneumonectomy greatly accelerates their recovery and, for a select group of patients, converts it into an outpatient procedure.
Since the mid 1980s, paper clinical pathways have been used in defining the road map of patient care. They have been used with varying degree of success for providing more cost-effective healthcare and helped to establish quality improvement models for healthcare delivery. Many attempts have been made to produce electronic versions of the paper clinical pathways in order to maximise benefits of the paper based systems. However, all paper systems are designed based on linear sequential model with little decision support capability. Current electronic versions of the paper systems produce only minimal improvements on the functionality of their paper counterparts. A state-transition information model (STIM) grounded in the Object Oriented system design paradigm is used to reconceptualise a computerised clinical pathways design. A computerised clinical pathways prototype is currently being developed based on this STIM model. The prototype will demonstrate improved functionality: better information management and decision support capabilities.
OBJECTIVE: To evaluate the cost of and clinical outcome of implementing a clinical pathway for laparoscopically assisted vaginal hysterectomy. STUDY DESIGN: A retrospective study of the case records of patients who underwent laparoscopically assisted vaginal hysterectomy before (May-December 1997) and after (January 1998-March 1999) implementation of a clinical pathway. Data regarding resource consumption and clinical outcome represented by 10 clinical indicators were collected. Student's t test and the chi 2 test were used, as appropriate. Statistical significance was set at P = .05. RESULTS: After implementation of the laparoscopically assisted vaginal hysterectomy clinical pathway, the average total fee decreased significantly, by 8.1% (P = .03), the average inpatient drug fee decreased by 50.6% (P < .01), and the laboratory fee dropped by 56.2% (P < .01). Furthermore, the length of hospital stay significantly decreased, from 6.90 to 4.08 days (P < .01); the average operation time decreased by 24.8% (P < .01); and the average anesthesia time decreased by 21.6% (P < .01). The pre-clinical pathway and post-clinical pathway complication rate did not differ statistically, but the rate of initiating intravenous antibiotic injections > 48 hours following surgery decreased by 76.2% in the clinical pathway group (P = .02). CONCLUSION: Implementation of a clinical pathway for laparoscopically assisted vaginal hysterectomy can improve health care outcomes by decreasing length of hospital stay and admission fees and by maintaining quality of care. The clinical pathway is a good policy for maintaining cost containment and high-quality patient care.