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PubMed1998

Benchmarking the perioperative process: III. Effects of regional anesthesia clinical pathway techniques on process efficiency and recovery profiles in ambulatory orthopedic surgery.

STUDY OBJECTIVES: (1) To incorporate regional anesthesia options for common outpatient orthopedic surgery into clinical pathways; (2) to use the clinical pathway format and the Procedural Times Glossary published by the Association of Anesthesia Clinical Directors (AACD) as management tools to measure postoperative same-day surgery processes and discharge outcomes; and (3) to determine the effects of general, regional, and combined general-regional anesthesia on these processes and outcomes. DESIGN: Hospital database and patient chart review of consecutive patients undergoing anterior cruciate ligament reconstruction (ACLR) during academic years (AY) 1995-1996 and 1996-1997. Patient data from AY 1995-1996, during which no intraoperative anesthesia clinical pathway existed, served as historical controls. Data from AY 1996-1997, during which intraoperative anesthesia clinical pathways were used, served as the treatment group. SETTING: Ambulatory surgery center in a teaching hospital. MEASUREMENTS AND MAIN RESULTS: The records of 503 ASA physical status I and II patients were reviewed. 1996-1997 patients selected general anesthesia (+/- femoral nerve block) or epidural anesthesia, after which the remainder of the perioperative anesthesia process was standardized with respect to the drugs and equipment used. 1995-1996 patients did not necessarily have a choice in anesthesia technique and did not have a standardized perioperative anesthetic course with respect to specific drugs and supplies. Intervals described in the AACD Procedural Times Glossary, anesthesia drug and supply costs, and patient outcome variables (postoperative nursing interventions required and unexpected admissions), as influenced by anesthesia technique used, were measured. Combined general-regional anesthesia care for ACLR in 1996-1997, when compared with general anesthesia alone, led to increased pharmacy and materials costs and increased turnover time. However, patients with the combined technique showed improved recovery profiles and lower unexpected admission rates, and they required fewer nursing interventions for common postoperative symptoms. Patients receiving epidural anesthesia showed discharge outcomes similar to those patients receiving general anesthesia with femoral nerve block. Postanesthesia care unit bypass (fast-tracking) was more likely in clinical pathway regional anesthesia patients, when compared with the clinical pathway general anesthesia used. CONCLUSIONS: Clinical pathway regional anesthesia care for outpatient orthopedics may have a significant role in simultaneously containing costs and improving both process efficiency and patient outcomes.

Adult↗
PubMed1997

The path to a clinical pathway: collaborative care for the patient with an ostomy.

A colostomy and ileostomy clinical pathway was developed at a southeastern teaching hospital in 1990 in response to excessive lengths of stay and costs at our hospital compared with national data for this patient group. A multidisciplinary clinical pathway team was formed and charged with the development, implementation, and ongoing monitoring of the clinical pathway tool and its effect on the outcomes of the population of patients with colostomies and ileostomies. Through this multidisciplinary collaboration, length of stay and cost have been reduced while quality care indicators have been maintained. This article presents the sample pathway we developed and describes the pathway development process, documentation, the variance analysis process, and the outcomes achieved with implementation. A urostomy/urinary diversion pathway that was developed after variance analysis review of the colostomy and ileostomy clinical pathway is also presented.

Analysis of Variance↗
PubMed2004

Physician-perceived barriers to adopting a critical pathway for unity-acquired pneumonia.

BACKGROUND: A proven efficacious and evidence-based critical pathway for community-acquired pneumonia (CAP) was implemented in six hospitals across a health service region (Edmonton, Canada). After one year (November 2000-November 2001), the pathway had reduced average length of stay by 1 day (from 10.8 to 9.8 days, p < .001). However, great variation was observed in physician adherence to the pathway. METHODS: Physician-perceived barriers to adoption of the CAP pathway were identified through in-depth interviews. Data saturation was reached after 10 physicians, representing a convenience sample of those willing to participate, were interviewed. RESULTS: Self-reported adherence to the CAP pathway was 75% (range 50%-100%). Qualitative analysis of the interview data indicated that comments could be grouped into five themes: (1) limited applicability, (2) lack of flexibility to accommodate atypical clinical presentations, (3) perception of insufficient evidence to support recommendations, (4) local organizational barriers, and (5) need for local adaptation. For example, one physician remarked that his community hospital had insufficient staff to support collection of lab samples for all patients. DISCUSSION: Interventions to increase pathway adoption and further improve quality of CAP care should address the identified barriers. For example, local audit and feedback of outcomes data to persuade physicians of the benefits of CAP pathways will need to be instituted.

Alberta↗
PubMed2005

Anomalous visual experiences, negative symptoms, perceptual organization and the magnocellular pathway in schizophrenia: a shared construct?

BACKGROUND: Schizophrenia is associated with impaired visual information processing. The aim of this study was to investigate the relationship between anomalous perceptual experiences, positive and negative symptoms, perceptual organization, rapid categorization of natural images and magnocellular (M) and parvocellular (P) visual pathway functioning. METHOD: Thirty-five unmedicated patients with schizophrenia and 20 matched healthy control volunteers participated. Anomalous perceptual experiences were assessed with the Bonn Scale for the Assessment Basic Symptoms (BSABS). General intellectual functions were evaluated with the revised version of the Wechsler Adult Intelligence Scale. The 1-9 version of the Continuous Performance Test (CPT) was used to investigate sustained attention. The following psychophysical tests were used: detection of Gabor patches with collinear and orthogonal flankers (perceptual organization), categorization of briefly presented natural scenes (rapid visual processing), low-contrast and frequency-doubling vernier threshold (M pathway functioning), isoluminant colour vernier threshold and high spatial frequency discrimination (P pathway functioning). RESULTS: The patients with schizophrenia were impaired on test of perceptual organization, rapid visual processing and M pathway functioning. There was a significant correlation between BSABS scores, negative symptoms, perceptual organization, rapid visual processing and M pathway functioning. Positive symptoms, IQ, CPT and P pathway measures did not correlate with these parameters. The best predictor of the BSABS score was the perceptual organization deficit. CONCLUSIONS: These results raise the possibility that multiple facets of visual information processing deficits can be explained by M pathway dysfunctions in schizophrenia, resulting in impaired attentional modulation of perceptual organization and of natural image categorization.

Adult↗
PubMedDate not supplied

Long-term maturation of visual pathways.

Previous research in adults has demonstrated the utility of the visual evoked potential (VEP) to measure the integrity of the chromatic and achromatic visual pathways. The VEP has also been shown to be a valuable indicator of maturation of these pathways in infants up to 1 year of age. The present manuscript reports changes in the visual pathways from 2 years to adulthood as measured by the spatio-chromatic VEP. The responses to achromatic reversal stimuli designed to preferentially activate the low spatial-frequency achromatic (luminance) pathways appear adult-like by 1 year of age. The responses to low spatial-frequency isoluminant onset stimuli designed to preferentially activate the chromatic pathway do not appear as they do in the adult until after 12-13 years of age. The shapes of the chromatic VEP waveforms shift from a positive-negative complex to a negative-positive complex. These changes can be modeled by a decrease in the latency of a large negative component between the ages of 1 year and adulthood. The results suggest that for low spatial-frequency stimuli, there are long-term changes in the development of the chromatic pathways that are not observed in the low spatial-frequency achromatic pathways. The changes in the chromatic VEP waveforms with age may be a physiological correlate of reported behavioral changes.

Adolescent↗
PubMed1998

Issues for the development of care pathways in mental health services.

AIMS: This paper seeks to discuss some of the issues for the development of care pathways for inpatients with schizophrenia. BACKGROUND: Managed care pathways are becoming increasingly popular for general adult conditions. Little is known about the development or application of care pathways for mental health services, and in particular, for inpatients diagnosed with schizophrenia. METHODS: Action research principles were adopted to engage and develop support to examine care pathways. Participant observation and unstructured interviews were the primary methods used during this phase of the research. The paper draws on the experiences of one of the authors (AJ) and his attempt to discuss the potential development of a care pathway for in-patients with schizophrenia in one inner city locality in London. FINDINGS: Four central issues were identified by the group; individualized care versus standardized care, generic practice and generic education. CONCLUSIONS: The development and application of care pathways for mental health services requires the consent and commitment from the work force. Many crucial barriers to development arose during the discussion groups and these will require further attention by prospective organizations wishing to apply care pathways to complex diagnostic groups such as schizophrenia.

Adult↗
PubMed2000

Implementation of hospital care pathways for patients with schizophrenia.

AIM: This paper aims to discuss some of the issues for the implementation of care pathways for inpatients suffering from schizophrenia. This paper builds upon a previously published paper describing the development of the care pathway. BACKGROUND: The use of a care pathway may enable care to be delivered in a more efficient and effective way. Very little is known about the development or implementation of care pathways for mental health conditions. METHODS: Action research guided the process of implementation and led to 29 in-depth interviews. Participant observation and records of 15 working group meetings rounded the data analysis. FINDINGS: The nature of the study site changed dramatically over the course of the research programme with many staff leaving the ward. This led to many problems in implementing the care pathway including poor levels of morale and engagement; how the patients were admitted and managed on the care pathway; poor levels of documentation. CONCLUSIONS: The findings are particular to this research environment, although some wider issues could be applicable to other sites such as the nature of representing psychiatric work on the care pathway; the evidence-based practice movement and the role of the user and individualized care.

Adult↗
PubMed2000

Variance analysis in clinical pathways for total hip and knee joint arthroplasty.

Clinical pathways are being increasingly used for daily patient care. The pathways consist of a sequence of critical treatment events matched to the patient's recovery. Variance analysis identifies deviations from the pathway and can be used for quality improvement and clinical audit. The aim of this study is to analyse the variances from clinical pathways in two common elective orthopaedic operations. A prospective variance analysis was performed from the clinical pathways of all patients undergoing total hip and total knee arthroplasty over a 12 month period. Variances were categorised according to their source and then further divided into serious and non-serious variances. A total of 65 patients underwent total knee replacement during the study. Eleven serious variances were recorded in eight of these patients (12.3%) with a surprisingly high number of cardiac events. A total of 52 patients underwent total hip replacement with nine serious variances recorded in seven of these patients (13.5%). Clinical pathways can be used as a means of incorporating evidence-based medicine into clinical practice. Variance analysis of the pathways can be utilised as a process of quality control and to improve patient outcomes. Serious variances within this study were higher than anticipated.

Adult↗
PubMed2003

Effectiveness of clinical pathways for total knee and total hip arthroplasty: literature review.

Although many hospitals have implemented clinical pathways to standardize the process of care, the effectiveness of clinical pathways for total hip and knee arthroplasties has not been reviewed critically. We searched for articles comparing outcomes of total hip or knee arthroplasty for patients who were treated using clinical pathways as opposed to patients treated without these pathways. Eleven studies met criteria for inclusion. Ten used historical controls, and 1 was a randomized trial. The studies had important methodological limitations. In general, the articles showed that patients treated using pathways experienced shorter hospital stays and lower costs, with comparable clinical outcomes as compared with patients treated without clinical pathways. We concluded that clinical pathways appear successful in reducing costs and length of stay in the acute care hospital, with no compromise in patient outcomes. However, interpretation of these studies is complicated by substantial methodological limitations, particularly the use of historical controls and failure to account for length of stay in rehabilitation facilities.

Arthroplasty, Replacement, Hip↗
PubMed2005

Cost unit accounting based on a clinical pathway: a practical tool for DRG implementation.

Setting up a reliable cost unit accounting system in a hospital is a fundamental necessity for economic survival, given the current general conditions in the healthcare system. Definition of a suitable cost unit is a crucial factor for success. We present here the development and use of a clinical pathway as a cost unit as an alternative to the DRG. Elective coronary artery bypass grafting was selected as an example. Development of the clinical pathway was conducted according to a modular concept that mirrored all the treatment processes across various levels and modules. Using service records and analyses the process algorithms of the clinical pathway were developed and visualized with CorelTM iGrafix Process 2003. A detailed process cost record constituted the basis of the pathway costing, in which financial evaluation of the treatment processes was performed. The result of this study was a structured clinical pathway for coronary artery bypass grafting together with a cost calculation in the form of cost unit accounting. The use of a clinical pathway as a cost unit offers considerable advantages compared to the DRG or clinical case. The variance in the diagnoses and procedures within a pathway is minimal, so the consumption of resources is homogeneous. This leads to a considerable improvement in the value of cost unit accounting as a strategic control instrument in hospitals.

Accounting↗
PubMed2003

Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection.

BACKGROUND: Patient care pathways have been developed for operative procedures with documented improvements in length of stay and cost without compromising outcome. The average hospital stay after colonic resection is 5 to 10 days. This study describes a clinical pathway for colon resections and examines patient outcome before and after institution of the pathway. METHODS: One hundred thirty-eight patients underwent elective colon resections at our institution by a single surgeon before (n = 52) and after (n = 86) introduction of a clinical pathway. Length of stay, postoperative complications, readmissions, and cost per patient were compared between the 2 groups. RESULTS: Mean total length of stay (+/- standard deviation [SD]) was less in the postclinical pathway patients (3.7 +/- 1.5 days) compared to preclinical pathway patients (6.6 +/- 3.3 days) (P <.001). When adjusted for age, sex, diagnosis, and type of operation, the difference in length of stay remains statistically significant (P <.001). There was 1 readmission in the prepathway group and 8 readmissions in the postpathway group. When the readmissions were added to the original admissions, the mean length of stay in the postpathway patients was 4.2 +/- 2.8 days and in the prepathway patients was 6.9 +/- 4.1 days (P <.001). The average cost per patient (+/- standard error of the mean), with readmission costs added, was 9310 +/- 5170 US dollars in the prepathway group and 7070 +/- 3670 US dollars in the postpathway group (P =.002). CONCLUSIONS: The institution of a clinical pathway for elective, open colon resections can be done safely with improvements in cost and length of stay.

Adult↗
PubMed2005

Clinical pathways in 17 European Union countries: a purposive survey.

We undertook a survey of clinical pathways across the 25 European Union countries, Australia. Fifty-one questionnaires were completed by largely self-selected experts from 17 countries. Respondents reported that pathways were important and were becoming increasingly widely used (although the rate of progress was highly variable). One important constraint was reported to be a cultural aversion among doctors that arises at least in part from the implication that pathways require multidisciplinary teamwork which will prejudice medical autonomy. In other words, pathways challenge clinical professional sub-cultures. Other constraints included lack of encouragement by external parties, such as purchasers, with limited financial support for pathway development and implementation and service purchasing that did not reward care providers who use pathways. The obvious implication of the survey is that more needs to be done to achieve a common understanding of pathways. In spite of the large quantity of published papers, survey respondents reported that there are many health professionals who have only a superficial understanding at best.

Attitude of Health Personnel↗
PubMed1979

Surface-associated heparin inhibits zymosan-induced activation of the human alternative complement pathway by augmenting the regulatory action of the control proteins on particle-bound C3b.

Discrimination by the human alternative pathway between activating and nonactivating particles occurs after deposition of C3b by the continuous low-grade interaction of the alternative pathway components in biologic fluids and is dependent on the modulation by surface constituents of the interaction of bound C3b with the control proteins, beta 1H, and C3b inactivator (C3bINA). When heparin glycosaminoglycan was coupled to activating particles, such as zymosan or Sepharose, by cyanogen bromide activation, their capacity to activate the human alternative pathway was inhibited. The loss of alternative pathway-activating capacity was directly correlated to the number of heparin molecules bound/zymosan particle, whether the ratio was varied by increasing the amounts of heparin in the initial coupling reactions or by treating a fully inhibited particle with incremental concentrations of heparinase. Analysis by linear regression of the inhibitory effect of each procedure (r = 0.97, r = 0.98, respectively) for adjusting the number of heparin molecules/particle revealed that the dose-response relationships were identical and that complete inhibition occurred with greater than 12 X 10(8) molecules of heparin/zymosan particle. The coupling of heparin to zymosan did not impair the uptake of C3b from the fluid-phase interaction of C3, B, and D, and did not alter the capacity of bound C3b to associate with B so as to permit its inactivation by D. Although the regulatory proteins present in normal serum chelated with EDTA or presented as a combination of purified C3bINA and beta 1H were relatively inefficient in inactivating C3b function on an activating particle of the alternative pathway such as zymosan or zymosan-cyanogen bromide, the control proteins rapidly inactivated C3b on a nonactivating particle wuch as a sheep erythrocyte or zymosan with coupled heparin. The increased numbers of C3b sites susceptible to inactivation by C3bINA in the presence of beta 1H were significantly correlated to the number of molecules of heparin/particle. By linear regression analysis of the correlation (r = 0.99) the number of heparin molecules/particle required to promote total inactivation of bound C3b by purified control proteins was 13.8 X 10(6). This molecular analysis suggests that the action of heparin coupled to an activating particle of the alternative pathway is to promote the interaction between particle-bound C3b and the regulatory proteins, thereby preventing particle-associated amplified C3 cleavage. It is noteworthy that both surface constituents known to maintain a particle as a nonactivator of the alternative pathway, sialic acid and N-sulfated mucopolysaccharide, act by facilitating the inactivation by regulatory proteins of the function of particle-bound C3b.

Complement Activation↗
PubMed1998

Trajectories of cholinergic pathways within the cerebral hemispheres of the human brain.

All sectors of the human cerebral cortex receive dense cholinergic input. The origin of this projection is located in the Ch4 cell group of the nucleus basalis of Meynert. However, very little is known about the location of the pathways which link the cholinergic neurons of the nucleus basalis to the human cerebral cortex. This question was addressed in whole-hemisphere sections processed for the visualization of multiple cholinergic markers. Two highly organized and discrete bundles of cholinergic fibres extended from the nucleus basalis to the cerebral cortex and amygdala and were designated as the medial and lateral cholinergic pathways. These bundles contained acetylcholinesterase, choline acetyltransferase and nerve growth factor receptors, confirming their cholinergic nature and origin within the basal forebrain. The medial pathway joined the white matter of the gyrus rectus, curved around the rostrum of the corpus callosum to enter the cingulum and merged with fibres of the lateral pathway within the occipital lobe. It supplied the parolfactory, cingulate, pericingulate and retrosplenial cortices. The lateral pathway was subdivided into a capsular division travelling in the white matter of the external capsule and uncinate fasciculus and a perisylvian division travelling within the claustrum. Branches of the perisylvian division supplied the frontoparietal operculum, insula and superior temporal gyrus. Branches of the capsular division innervated the remaining parts of the frontal, parietal and temporal neocortex. Representation of these cholinergic pathways within a 3D MRI volume helped to identify white matter lesion sites that could interfere with the corticopetal flow of cholinergic pathways.

Adult↗
PubMedDate not supplied

Application of a prototype process for developing a tube gastrostomy clinical pathway.

The development and implementation of clinical pathways as a managed care tool have been widely embraced as principal components of the healthcare industry's drive to reform costly, inconsistent, and often uncontrolled delivery of services. Clinical pathways are not new to healthcare; however, the lack of a defined and systematic process for pathway development has hindered organizational efforts to develop and implement clinical pathways. A multidisciplinary clinical pathway process prototype was identified as a means for effectively defining and linking care and outcomes for patients requiring tube gastrostomy placement at a large military medical facility. This article presents the prototype process for developing a clinical pathway with a practical application to illustrate the process and provides a process template for potential use by others interested in developing multidisciplinary clinical pathways.

Critical Pathways↗
PubMed2002

Impaired subcortical and cortical sensory evoked potential pathways in septic patients.

OBJECTIVE: Sensory evoked potential (SEP) peak latencies were recorded in order to evaluate the incidence and severity of septic encephalopathy, testing the hypothesis that the occurrence of septic encephalopathy is more frequent than generally assumed. DESIGN: Prospective cohort study. SETTING: Medical intensive care unit of a university hospital. PATIENTS: Sixty-eight critically ill patients were studied within 48 hrs after the development of severe sepsis (n = 41) or septic shock (n = 27). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Septic encephalopathy was defined as prolongation of SEP peak latencies beyond the upper limit of the reference range of subcortical (N13-N20 interpeak latency) and cortical SEP pathways (N20-N70 interpeak latency), as well as asymmetry of peak latencies marked by the presence of subclinical cerebral focal signs. Subcortical SEP pathways were impaired in 34% and cortical SEP pathways in 84% of all patients. The prolongation of the cortical SEP pathway correlated with the Acute Physiology and Chronic Health Evaluation III score (r = 0.23; p <.0001). SEP peak latencies did not differ in patients with severe sepsis compared with those with septic shock. Subclinical cerebral focal signs were present in 24% of the subcortical SEP pathways and in 6% of the cortical SEP pathways. CONCLUSIONS: Septic encephalopathy occurs more frequently than generally assumed, and its severity is associated with the severity of illness. The impairment of subcortical and cortical SEP pathways was not different between patients with severe sepsis and those with septic shock.

Brain Diseases↗
PubMed2006

Acute behavioural stress facilitates long-term depression in temporoammonic-CA1 pathway.

Behavioural stress facilitates long-term depression in Schaffer collaterals-CA1 pathway, but it is unknown whether it influences long-term depression in temporoammonic fibres-CA1. Here, we report that low-frequency stimulation induced long-term depression and foot shock stress before slice preparation facilitated long-term depression in both pathways of young rat slices. When the field excitatory postsynaptic potentials were recorded by stimulating the two pathways alternately and low-frequency stimulation was given to the two pathways simultaneously, a reliable long-term depression was induced in Schaffer collaterals-CA1 but a reliable long-term potentiation took place in temporoammonic fibres-CA1. Interestingly, foot shock stress now enabled low-frequency stimulation to induce reliable long-term depressions in both pathways. These findings suggested that acute behavioural stress facilitated long-term depressions in both pathways and disrupted the interactions between pathways.

Animals↗
PubMed1980

Activation of the alternative complement pathway by extracts of cotton dust.

Extracts of cotton dust were tested for their ability to activate the alternative complement pathway in fresh normal human serum (NHS). Alternative pathway activation was determined by a haemolytic assay utilizing glutathione-sensitized human erythrocytes, consumption of alternative pathway components in terms of alternative pathway CH50 units and an immunoelectrophoretic assay to detect split products of activation of factor B. All assays were performed under conditions that have been shown to block the initial steps of classical pathway activation but permit activation of the alternative complement pathway. Results demonstrate that the cotton dust extracts could consume alternative complement pathway proteins in a dose-response manner. The complement activating factor is probably endotoxin since a cotton dust extract obtained by an extraction method for endotoxin yielded the greatest activity.

Complement Activation↗