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PubMed2006

[Clinical pathways in view of cost effects in the DRG system].

Clinical pathways constitute a useful tool for structuring diagnostic and therapeutic measures during the period of inpatient treatment. They primarily serve to ensure and improve quality and only secondarily to reduce costs. International experience in evaluating clinical pathways confirms these statements. The introduction of clinical pathways across disciplines and professional groups succeeds when the treatment team can be motivated to accept this concept. Only when this is achieved will it be possible for clinical pathways to lead to improved results for the patient as well as the hospital while simultaneously reducing costs and length of hospital stay.

Communication↗
PubMed2000

The effects of a pediatric unilateral inguinal hernia clinical pathway on quality and cost.

BACKGROUND/PURPOSE: The purpose of this study is to discover whether a pediatric inguinal hernia surgical clinical pathway (CP) reduces the frequency of wound infections, return visits, times associated with surgical repair, or costs. METHODS: A multidisciplinary team developed the inguinal hernia surgical clinical pathway. Healthy children greater than 50 weeks gestational age who required unilateral hernia repair were considered for the study. Two groups were formed: (1) an intervention group selected randomly (n = 46, CI = 95%, power = .80) from patients enrolled from November 1996 through April 1997, and (2) a retrospective cohort control group (n = 46) matched to each intervention patient by age, gender, and medical history. Analysis of variance and chi2 testing were used to test for significant differences between the 2 groups in postoperative wound infections, readmission and emergency department return visits within 72 hours, times associated with surgical repair, and costs. RESULTS: There were no significant differences in postoperative wound infections, times associated with surgical repair, or readmission rates within 72 hours. Total cost significantly decreased, by 10% (P< or = .05), for pathway patients ($982 v $880). CONCLUSION: These results show that the use of a pediatric inguinal hernia surgical clinical pathway is associated with reduced cost while maintaining quality of care.

Child, Preschool↗
PubMed1996

Insulin regulation of phosphoenolpyruvate carboxykinase gene expression does not require activation of the Ras/mitogen-activated protein kinase signaling pathway.

Expression of phosphoenolpyruvate carboxykinase (PEPCK), the rate-limiting step in hepatic gluconeogenesis, is primarily regulated at the level of gene transcription. Insulin and phorbol esters inhibit basal PEPCK transcription and antagonize the induction of PEPCK gene expression by glucocorticoids and glucagon (or its second messenger cAMP). Insulin activates a signaling cascade involving Ras --> Raf --> p42/p44 mitogen-activated protein (MAP) kinase kinase (MEK) --> p42/p44 MAP kinase (ERK 1 and 2). Recent reports suggest that activation of this Ras/MAP kinase pathway is critical for the effects of insulin on mitogenesis and c-fos transcription but is not required for insulin action on metabolic processes such as glycogen synthesis, lipogenesis, and Glut-4-mediated glucose transport. We have used three distinct approaches to examine the role of the Ras/MAP kinase pathway in the regulation of PEPCK transcription by insulin in H4IIE-derived liver cells: (i) chemical inhibition of Ras farnesylation, (ii) infection of cells with an adenovirus vector encoding a dominant-negative mutant of Ras, and (iii) use of a chemical inhibitor of MEK. Although each of these methods blocks insulin activation of MAP kinase, none alters insulin antagonism of cAMP- and glucocorticoid-stimulated PEPCK transcription. Although phorbol esters activate MAP kinase and mimic the effects of insulin on PEPCK gene transcription, inhibition of MEK has no effect on phorbol ester inhibition of PEPCK gene transcription. Using the structurally and mechanistically distinct phosphatidylinositol 3-kinase (PI 3-kinase) inhibitors, wortmannin and LY 294002, we provide further evidence supporting a role for PI 3-kinase activation in the regulation of PEPCK gene transcription by insulin. We conclude that neither insulin nor phorbol ester regulation of PEPCK gene transcription requires activation of the Ras/MAP kinase pathway and that insulin signaling to the PEPCK promoter is dependent on PI 3-kinase activation.

Alkyl and Aryl Transferases↗
PubMedDate not supplied

Variation in the process of pediatric asthma care.

In May 1994, the continuous quality improvement team at Hermann Children's Hospital in Houston, TX, began to study the structure, process, and outcome of asthma care for pediatric patients. The team's immediate goals were to identify variation in the treatment of pediatric asthma and to determine the most cost-effective interventions. This article details the team's development of a clinical pathway to reduce variation in patient care; use of the pathway led to a reduction in length of stay and a corresponding reduction in costs.

Adolescent↗
PubMed2002

Shoulder pain after stroke: a review of the evidence base to inform the development of an integrated care pathway.

BACKGROUND: Shoulder pain is a common complication of stroke. It can impede rehabilitation and has been associated with poorer outcomes and prolonged hospital stay. This systematic review was undertaken to inform the development of an evidence-based integrated care pathway (ICP) for the management of hemiplegic shoulder pain (HSP). AIMS AND OBJECTIVES: 1) To provide a background understanding of the functional anatomy of the shoulder and its changes following stroke. 2) To review the literature describing incidence and causation of HSP and the evidence for factors contributing to its development. 3) To appraise the evidence for effectiveness of different interventions for HSP. METHODS: Data sources comprised a computer-aided search of published studies on shoulder pain in stroke or hemiplegia and references to literature used in reviews (total references = 121). MAIN FINDINGS: Although a complex variety of physical changes are associated with HSP, these broadly divide into 'flaccid' and 'spastic' presentations. Management should vary accordingly; each presentation requiring different approaches to handling, support and intervention. (1) In the flaccid stage, the shoulder is prone to inferior subluxation and vulnerable to soft-tissue damage. The arm should be supported at all times and functional electrical stimulation may reduce subluxation and enhance return of muscle activity. (2) In the spastic stage, movement is often severely limited. Relieving spasticity and maintaining range requires expert handling; overhead exercise pulleys should never be used. Local steroid injections should be avoided unless there is clear evidence of an inflammatory lesion. CONCLUSIONS: HSP requires co-ordinated multidisciplinary management to minimize interference with rehabilitation and optimize outcome. Further research is needed to determine effective prophylaxis and document the therapeutic effect of different modalities in the various presentations. Development of an integrated care pathway provides a reasoned approach to management of this complex condition, thus providing a sound basis for prospective evaluation of different interventions in the future.

Analgesics↗
PubMedDate not supplied

The potential of integrated multi-agency care pathways for children.

In 2004, a Framework for the Development of Integrated Multi-agency Care Pathways for Children with Life-Threatening and Life-Limiting Conditions, funded by the Department of Health, was developed by a working party. It included the Association for Children with Life-Threatening or Terminal Conditions and their Families, the Royal College of Nursing and the Royal College of Paediatrics and Child Health. This article will identify the need for this framework and its potential to transform the delivery of palliative care services to overcome present inequalities based on condition and geography that currently beset children with these conditions and their families. It will show how the three stages of the pathway (diagnosis or recognition, living with a condition, and end of life and bereavement) follow the patient's journey and complement guidance set out in the Children's National Service Framework (2004) for multi-agency assessments, protocols and standards to ensure high-quality coordinated care and services. It concludes with the need to evaluate the effectiveness of pathways that may develop from this initiative through audit and research.

Adaptation, Psychological↗
PubMedDate not supplied

Clinical pathways for managing patients receiving interleukin 2.

As biologic therapies enter the mainstream for cancer and HIV treatments, clinicians need the knowledge and expertise to safely and competently care for their patients who are undergoing these therapies. This article provides an overview of the immune system, emphasizing the elements that are affected by the biologic agent interleukin 2 (lL-2), lL-2 has been approved for use in the treatment of metastatic renal cell carcinoma and metastatic melanoma. Clinical trials currently are being conducted to determine its use in treating other cancers. The severity of side effects of lL-2 varies with the dose, route, and schedule of administration. The most common effects with all methods of administration are flu-like symptoms. Because the side effects of lL-2 are relatively predictable, clinical pathways offer practical tools for anticipating and managing the toxicities associated with lL-2 administration.

Antineoplastic Agents↗
PubMed1994

Costimulation by purified intercellular adhesion molecule 1 and lymphocyte function-associated antigen 3 induces distinct proliferation, cytokine and cell surface antigen profiles in human "naive" and "memory" CD4+ T cells.

Activation of resting human CD4+ "naive" (CD45RA+CD45RO-) and "memory" (CD45RA-CD45RO+) T cells requires costimulatory signals in addition to engagement of the T cell receptor/CD3 complex (TCR/CD3). The adhesion pathways mediated by lymphocyte function-associated antigen 1/intercellular adhesion molecule 1 (LFA-1/ICAM-1) and CD2/LFA-3 are capable of providing such costimulatory signals. Our work shows that these costimulatory adhesion pathways are critically involved in regulation of T cell differentiation/maturation. Evidence for subset-specific costimulatory requirements is demonstrated by the finding that only memory CD4+ T cells were costimulated by LFA-3, whereas both naive and memory CD4+ T cells were costimulated by ICAM-1. In addition, these costimulatory adhesion pathways regulated reciprocal cytokine secretion patterns for interleukin 5 (IL-5) and granulocyte/macrophage colony-stimulating factor (GM-CSF). Repeated costimulation of CD4+ memory T cells with LFA-3 led to secretion of high levels of IL-5, while repeated costimulation with ICAM-1 induced high levels of secreted GM-CSF. Significant interferon gamma (IFN-gamma) production was observed with either of the costimulatory ligands. Extensive cell surface analysis of these in vitro cultures of peripheral blood derived memory CD4+ T cells, with monoclonal antibodies obtained from the 5th Leucocyte Typing Workshop, revealed differential expression of a singular antigen, CD60. This antigen was preferentially expressed on LFA-3-costimulated cells suggesting a positive correlation between CD60 expression and a T helper type 2-like cytokine profile. In conclusion, this report demonstrates a new functional role for costimulatory adhesion molecules in regulating differential cytokine secretion in human memory CD4+ T cells.

Antibodies, Monoclonal↗
PubMed2005

Combined haploinsufficiency for ATM and RAD9 as a factor in cell transformation, apoptosis, and DNA lesion repair dynamics.

Loss of function of oncogenes, tumor suppressor genes and DNA damage processing genes has been implicated in the development of many types of cancer, but for the vast majority of cases, there is no link to specific germ line mutations. In the last several years, heterozygosity leading to haploinsufficiency for proteins involved in DNA repair pathways was shown to play a role in genomic instability and carcinogenesis after DNA damage is induced. Because the effect of haploinsufficiency for one protein is relatively small, we hypothesize that predisposition to cancer could be a result of the additive effect of heterozygosity for two or more genes, critical for pathways that control DNA damage signaling, repair or apoptosis. To address this issue, primary mouse cells, haploinsufficient for one or two proteins, ATM and RAD9, related to the cellular response to DNA damage were examined. The results show that cells having low levels of both ATM and RAD9 proteins are more sensitive to transformation by radiation, have different DNA double-strand break repair dynamics and are less apoptotic when compared with wild-type controls or those cells haploinsufficient for only one of these proteins. Our conclusions are that under stress conditions, the efficiency and capacity for DNA repair mediated by the ATM/RAD9 cell signaling network depend on the abundance of both proteins and that, in general, DNA repair network efficiencies are genotype-dependent and can vary within a specific range.

Animals↗
PubMed1996

Clinical pathways: benefits and liabilities.

Clinical paths can be powerful mechanisms to prevent malpractice litigation or they can present liability issues. Common negligence issues for nurses related to clinical paths are examined as well as crucial areas of malpractice vulnerability.

Critical Pathways↗
PubMed2006

[Clinical pathways. Implementation in a urological department].

BACKGROUND: Clinical pathways are directions for standardised treatment processes for different diseases or procedures in a hospital. These pathways are developed within a team of several professions and are used as order and procedure sheets. Experiences with this element of quality management are limited in Germany. METHODS: The development and the implementation process of 15 pathways in a urological department are described. A clinical pathway for female incontinence surgery (suburethral tape) is presented as an example. The effects of the pathways are evaluated on a routine basis. RESULTS: Seventy-two percent of the patients were treated according to a clinical pathway. The advantages of clinical pathways are a better structuring and transparency of medical processes, a reduction of documentation, improvements in medical education and savings in time, hospital stay of the patients and costs. Expenses for pharmaceuticals were significantly reduced in connection with development of the pathways. CONCLUSIONS: The implementation of clinical pathways is a complex but rewarding project. It can be expected that clinical pathways will be rapidly distributed in the near future and that they will contribute to improvements of health care quality.

Critical Pathways↗
PubMed2005

Colorectal clinical pathways: a method of improving clinical outcome?

OBJECTIVE: Clinical pathways are intended to improve the quality of care. In March 2001, our unit implemented a pathway for patients undergoing major colorectal surgery. The aim of this study was to assess its impact on the quality of patient care. METHODS: We reviewed 204 patients managed using this pathway in 2001, and compared their outcomes with those of a control group of 204 patients who had undergone similar procedures the year before. The endpoints measured were postoperative morbidity, length of stay and readmission rates. RESULTS: Both groups were similar in terms of patient demographics, diagnosis, and nature of surgery performed. In the study group, 61% of patients underwent elective surgery compared with 62% in the control group. The incidence of postoperative morbidity in the study group was 20% compared with 33% in the control group (p = 0.003). The rate of readmission as a result of surgical complications was 6% in the study group versus 13% in the control group (p = 0.029). The average length of stay was 10.4 days in the study group and 12.1 days in the control group (p = 0.105). CONCLUSION: The introduction of a colorectal clinical pathway significantly improved the outcome of patients undergoing major colorectal surgery.

Adolescent↗
PubMed1996

Waiting times: the search for equitable solutions. Case study: Mater Misericordiae Adult Public Hospital Continuum of Care Model.

For the survival of any health care organisation, evidence-based practice is fundamental, particularly in today's economic climate. The Mater Misericordiae Adult Public Hospital in Brisbane is committed to providing a flexible health care system that is responsive and accountable to the needs of the customers. As part of the Mater's continuous quality improvement program, a Continuum of Care Service Delivery Model was developed. This model comprises many innovative clinical management systems which have evolved over recent years. Clinical pathways, care management, pre-admission clinics, variance management and evidence-based practice are core components of the model.

Admitting Department, Hospital↗
PubMed2006

The development of an Integrated Care Pathway for all patients with advanced life-limiting illness - the Supportive Care Pathway.

AIM: To describe the development and implementation of an Integrated Care Pathway for all patients with advanced life-limiting illness who have been admitted to hospital. BACKGROUND: This pathway, called the Supportive Care Pathway, has been developed not only in response to the national drivers to improve end of life care, but also in recognition of local survey data which demonstrated the need for strategies to support the provision of palliative care. The pathway is aimed primarily at generalist staff who may have a significant number of patients with palliative care needs on their wards, though not necessarily yet in the last days of life. METHOD: The pathway, which is being piloted on three elderly care wards in the West Midlands, has been developed in line with accepted Integrated Care Pathway methodology and is being evaluated using the Integrated Care Pathways Assessment Tool. RESULTS: The pathway has been well received by staff using it and early evaluation of its effect in improving documentation of care is encouraging. CONCLUSIONS: Unacceptable variations in care for those nearing the end of life is recognized. It is believed that the use of the Supportive Care Pathway may help to reduce that variation by identifying and supporting patients thought to be in the last year of their life.

Aged↗
PubMed2005

Pathway management in ambulatory wound care: defining local standards for quality improvement and interprofessional care.

Growing health care costs and changes in health care delivery, such as the adoption of the diagnosis-related groups, have tremendously affected treatment patterns all over the world. Pathway management is suitable to be responsive to the growing operating requirements and to manage effective and efficient medical care in hospitals. Pathways standardise clinical processes for patients with a similar diagnosis, procedure or symptom thereby optimising the quality of treatment and patient satisfaction. They are utilised by a multidisciplinary team with a primary focus on quality and coordination of care. Considering the key strategies of pathway management, an interprofessional team containing physicians and nurses developed and implemented a clinical pathway for ambulatory treatment of chronic wounds. A precise medical protocol was created to standardise routine procedures, to improve the treatment outcome and to provide an integrated documentation that enhances interprofessional collaboration. We designed a modular concept of four different sheets which provide pre-defined standards: (a) medical admission, (b) findings and history, (c) topic and systemic treatment and (d) evaluation of outcome criteria. Variances must be merely written down in detail. After 1 year in clinical practice, we state that the use of a clinical pathway for chronic wound management is an effective method of improving clinical processes and patient outcomes.

Ambulatory Care↗