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PubMedDate not supplied

A clinical pathway for the secondary diagnosis of alcohol misuse: implications for the orthopaedic patient.

This article presents the process of developing a method of routine identification, assessment, intervention, and follow-up for the trauma patient with a concomitant diagnosis of alcohol misuse. A clinical pathway approach to addressing the needs of the alcohol misuser is outlined, and an alternative method that adapts this approach to other settings is also presented. Ever mindful of decreasing lengths of stay and reimbursement predicated on diagnosis-related groups, this pathway is tailored to overlay onto an existing clinical path of care so as not to increase length of stay nor duplicate services.

Alcoholism↗
PubMed1998

Bone marrow path saves up to $100,000 per case.

The bone marrow transplantation pathway at Richland Memorial Hospital in Columbia, SC, has reduced length of stay by 8.6 days and cut costs per case by up to $100,000. The 44-day pathway, implemented in 1995, incorporated three major changes in the care of bone marrow transplant patients: beginning the inpatient stay with the first day of conditioning therapy; deleting some routine lab tests and rescheduling others; and giving medications orally rather than intravenously whenever possible. By using the pathway as an audit tool, case managers at Richland Memorial also improved documentation and helped staff better understand the bone marrow transplantation protocols.

Bone Marrow Transplantation↗
PubMed1998

Case management goes global.

As the global population ages and countries seek to privatize their national health systems, more and more hospitals overseas are turning to case management as a way to get a handle on health care costs. Even in advanced nations like Great Britain, however, the profession remains in a state of infancy. Cost data are often difficult to come by, and until recently, physicians and medical staff have not been held accountable for the quality of services they provide. Clinical pathways are also becoming popular abroad because they can serve as a means of identifying best practices and can help to reduce the fragmentation that has characterized health care overseas.

Benchmarking↗
PubMed1998

Facilitating care management through computerized clinical pathways.

The development and implementation of clinical pathways at New York University Medical Center and the transition to a computerized multidisciplinary documentation system took place between 1995 and 1998. Both the computerized system and the pathway program evolved simultaneously over this 3-year period. The article describes the process of creating the clinical pathways and the automated documentation system to support the clinical pathways. Migration from the paper pathway to the automated system required the efforts of an interdisciplinary team, which focused on issues such as translation of written pathway detail into language that could be loaded into the automated system. The advantages, pitfalls, and lessons learned in this integration experience are also described.

Automation↗
PubMed2000

The development of a stroke clinical pathway: an experience in a medium-sized community hospital.

Patients with acute ischemic strokes were studied in a medium-sized community hospital in Mississippi. Studies were done before and after implementation of the stroke clinical care pathway with emphasis on the following clinical indicators: 1) performance of a brain CT scan, 2) the search for the etiology of the stroke, 3) whether the patient was treated emergently for hypertension, 4) the use of measures to prevent deep-vein thrombosis, and 5) prophylactic drug treatment against recurrent stroke after hospital discharge. Following application of the clinical pathway, there was a significant improvement in all the clinical indicators that were felt to require further attention and none had a setback. The length of hospital stay was decreased, and there was no significant increase in the hospital costs in the post-pathway study despite an increase in the number of diagnostic and therapeutic procedures performed. When applied properly, clinical pathways can effectively mobilize hospital resources, maximize quality of care, and at the same time minimize costs.

Aged↗
PubMed2002

Prospective evaluation of a chest pain pathway at Green Lane Hospital.

AIMS: To prospectively evaluate the efficacy and safety of a chest pain pathway at Green Lane Hospital. METHODS: Between August 1999 and March 2000, patients with non-traumatic chest discomfort considered to be possibly ischaemic were assessed by history, physical examination, baseline electrocardiographic findings and point of care troponin T tests. Those considered not to be high risk entered the pathway which included repeat cardiac markers and electrocardiograms at 6-8 hours, followed by optional stress testing. The patients were followed for at least one year. RESULTS: Of 423 patients with chest discomfort compatible with myocardial ischaemia, 173 were enrolled in the pathway, with 19 later transferred off the pathway for clinical reasons. Of the remaining 154 patients, the median duration of hospital stay was 17.3 hours [IQR 8.2, 25.1] (median of 13.1 hours for those who did not undergo stress testing); 111 (72%) stayed in hospital for less than 24 hours. There were no readmissions within 30 days with an acute coronary syndrome. In the year following discharge, three patients had a myocardial infarction (one of whom later died) and four died of non-cardiac causes. At one year, freedom from cardiac death or non-fatal myocardial infarction was 98% [95%CI 95,100]. CONCLUSIONS: The chest pain pathway facilitated patient triage and patients had high event-free survival.

Aged↗
PubMed1997

The development of outcome statements for burn care.

This article chronicles the development of an American Burn Association consensus document reflecting optimal goals for the delivery of burn care for use in clinical pathways and other quality improvement efforts. Outcome statements can measure progress toward meeting patient goals and can identify barriers in delivering optimal patient care.

Burns↗
PubMed2003

A hospital care pathway for alcohol.

Inappropriate placing of alcohol misusers on gastroenterology wards spurred the two ward managers into leading a campaign for better diagnosis, placement and treatment of these patients.

Alcoholism↗
PubMed2005

An active metabolite of leflunomide, A77 1726, inhibits the production of serum amyloid A protein in human hepatocytes.

OBJECTIVE: Cytokine-induced hepatic serum amyloid A (SAA) synthesis is the critical step in the pathogenesis of AA amyloidosis secondary to rheumatoid arthritis (RA). This study was conducted to provide more insight into the mechanism of SAA production in hepatocytes and its regulation. METHODS: Primary cultured normal human hepatocytes were stimulated with cytokines (IL-1beta, TNF-alpha and IL-6) and the culture supernatants were analysed for the production of SAA. Human hepatocytes, treated or not treated with A77 1726, were stimulated with IL-1beta and the cellular lysates were analysed by immunoblot using anti-phospho-specific mitogen-activated protein kinase (MAPK) and IkappaB-alpha. Acute phase-SAA (SAA1) mRNA expression was analysed by reverse transcription-polymerase chain reaction. RESULTS: IL-1beta is a most potent inducer of SAA in normal hepatocytes. A77 1726 suppressed the production of SAA in human hepatocytes activated by IL-1beta in a dose-dependent manner (0-50 microM). A77 1726 inhibited IL-1beta-induced p38 and c-Jun N-terminal kinase 1/2 (JNK1/2) activation, whereas A77 1726 did not affect IL-1beta-induced NF-kappaB activation in hepatocytes. CONCLUSION: These results indicate that MAPK signalling pathways are critical in IL-1beta-induced hepatic SAA synthesis. Leflunomide may suppress SAA synthesis by affecting these pathways and may therefore have some beneficial effect on AA amyloidosis secondary to RA.

Aniline Compounds↗
PubMed2000

Improvement of health outcomes after continued implementation of a clinical pathway for radical nephrectomy.

The clinical pathway is an important tool for outcome management. We evaluated the overall effects of the continued implementation of a clinical pathway for radical nephrectomy on the length of hospital stay, admission charges, and the quality of medical care. The data obtained from the second-year implementation (group 3) of the clinical pathway were compared with the data from the first-year implementation (group 2) and the year preceding implementation (group 1). Thirty-seven consecutive patients with renal cell carcinoma underwent radical nephrectomy in group 1, 47 in group 2, and 55 in group 3; all were enrolled in this study. The length of hospital stay, average admission charges, and 8 quality indicators were measured in these patients. We also evaluated the variances in the implementation of the clinical pathway. The mean length of stay decreased by 14.0% (P = 0.0048) in group 2, and by 15.8% (P= 0.0014) in group 3, when compared to group 1. The total admission charges significantly decreased by 19.0% (P = 0.001) in group 2, and by 27.9% (P < 0.0001) in group 3, compared to the charges for group 1. A continued decrease in charges for operation and anesthesia, laboratory, pharmacy, and others were found 2 years after implementation of the clinical pathway. Among the 8 quality indicators, 2 were continuously improved in the second-year implementation of the clinical pathway, 2 were improved significantly in the second-year implementation only, and 4 showed no significant change at all. Variances from the clinical pathway decreased significantly after continued implementation. Continued implementation of the clinical pathway for radical nephrectomy can improve a physician's practice continuously by decreasing the length of hospital stay, admission charges, and variances, and by improving quality. However, the improved results after implementation of the clinical pathway should be maintained carefully to assure good health care.

Adult↗
PubMed1997

Pulmonary lobectomy patient care pathway: a model to control cost and maintain quality.

BACKGROUND: Cost containment is a reality in thoracic surgery. Patient care pathways have proved effective in cardiac surgery to reduce length of stay and control costs. METHODS: A multidisciplinary team formulated a pulmonary lobectomy patient care pathway to standardize care, reduce length of stay and costs, and maintain quality. Variance codes were developed to collect data prospectively on reasons for prolonged stay. A patient satisfaction survey was instituted to learn patients' responses to their hospitalization. RESULTS: One hundred forty-seven patients underwent lobectomy in 1995 before institution of the pathway with a mean length of stay of 10.6 days and a mean cost of $16,063. The lobectomy pathway was instituted at the beginning of 1996. One hundred thirty patients underwent lobectomy in 1996 with a mean length of stay of 7.5 days (p = 0.03) and a mean cost of $14,792 (p = 0.47). Readmission and mortality rates were unchanged. Eighty-eight of 130 patients (68%) were able to be discharged by the target length of stay of 7 days in 1996 as opposed to 76 of 147 patients (52%) in 1995. The most common reason for delayed discharge was inadequate pain control. The majority of patients felt prepared for discharge by the seventh postoperative day (70 of 96 patients, 73%). CONCLUSIONS: The institution of a lobectomy patient care pathway appeared to reduce length of stay and costs. The pathway provided a framework to begin systematic quality control measures to enhance patient care.

Cost Control↗
PubMed1998

Prevalence of subacute patients in acute care: results of a study of VA hospitals.

Subacute care is a transitional level of care for medically stable patients who no longer require daily diagnostic/invasive care but require more intensive care than is typical in a skilled care facility. A Congressionally mandated study was undertaken to determine the number of VA patients with subacute needs being cared for in acute care. InterQual, Inc. subacute care criteria were retrospectively applied to 858 medical and surgical admissions from 43 VA hospitals. Over one-third contained at least one subacute day; with an average length of stay (LOS) of 12.7 days (SD = 12.4); of which 6.8 days were subacute. Patients with these admissions had significantly longer LOSs, were older, and were more likely to die or to be discharged to a nursing home. Diagnoses with subacute days included COPD, pneumonia, joint replacement, and cellulitis. Future studies should develop clinical pathways to prospectively manage admissions with subacute needs and then evaluate their effectiveness.

Age Factors↗
PubMed2003

Cross-talk between the Notch and TGF-beta signaling pathways mediated by interaction of the Notch intracellular domain with Smad3.

The Notch and transforming growth factor-beta (TGF-beta) signaling pathways play critical roles in the control of cell fate during metazoan development. However, mechanisms of cross-talk and signal integration between the two systems are unknown. Here, we demonstrate a functional synergism between Notch and TGF-beta signaling in the regulation of Hes-1, a direct target of the Notch pathway. Activation of TGF-beta signaling up-regulated Hes-1 expression in vitro and in vivo. This effect was abrogated in myogenic cells by a dominant-negative form of CSL, an essential DNA-binding component of the Notch pathway. TGF-beta regulated transcription from the Hes-1 promoter in a Notch-dependent manner, and the intracellular domain of Notch1 (NICD) cooperated synergistically with Smad3, an intracellular transducer of TGF-beta signals, to induce the activation of synthetic promoters containing multimerized CSL- or Smad3-binding sites. NICD and Smad3 were shown to interact directly, both in vitro and in cells, in a ligand-dependent manner, and Smad3 could be recruited to CSL-binding sites on DNA in the presence of CSL and NICD. These findings indicate that Notch and TGF-beta signals are integrated by direct protein-protein interactions between the signal-transducing intracellular elements from both pathways.

Animals↗
PubMed2005

Pathways to the diagnosis of colorectal cancer: an observational study in three UK cities.

BACKGROUND: Colorectal cancer can present in a variety of ways, and with any of several symptoms. Different referral routes from primary to secondary care cater for these different presentations. The route that has received most investment in the UK National Health Service is the 2-week clinic, but the proportions of patients taking this and other routes to diagnosis are largely unknown. METHODS: We designed an observational audit in Exeter, Oxford and Sheffield, UK. Colorectal cancers diagnosed in 2002 from participating practices were identified and the presence and timing of seven important clinical features noted: diarrhoea, constipation, rectal bleeding, abdominal pain, the finding of an abdominal or rectal mass on examination, anaemia and positive faecal occult blood tests. The referral pathways to secondary care were identified. RESULTS: Of the 151 patients studied, 112 (74%) were referred with at least one clinical feature of colorectal cancer to a specialist. Only 43 of these (28% of the total) were referred to a 2-week clinic; 39 patients (26% of the total) had an emergency admission, of whom 10 (7%) had their emergency admission after referral to a specialist for investigation but before a diagnosis had been established. The time intervals between the first consultation with a symptom of cancer and referral were mostly short. CONCLUSION: Patients with colorectal cancer travel several different pathways to diagnosis. The pathway with the most resources-the 2-week clinic-is used by a minority of patients.

Adult↗
PubMed1996

Geriatric patients with depression. Improving outcomes using a multidisciplinary clinical path model.

Clinical pathways define multidisciplinary staff members' responsibilities, time lines, and patient outcomes. Although medical and surgical care settings frequently use them to improve quality, clinical, and fiscal outcomes for specific patient populations, staff members of psychiatric care settings have been hesitant to use clinical pathways because psychiatry emphasizes patient individuality. The authors describe the development and implementation of a psychiatric clinical pathway for geriatric patients with depression and identify common multidisciplinary interventions and a pattern of outcomes over the course of treatment for these patients. They also delineate quality and fiscal outcomes and future directions. Implementation of the pathway has been successful, and the development and implementation processes have applicability to other patient populations and care settings.

Aged↗
PubMedDate not supplied

Development and implementation of clinical pathways for the management of four trauma diagnoses.

Clinical pathways are similar to the production algorithms developed by industry. They are being adapted for use in healthcare to reduce resource utilization, decrease variability, and control expenditures. At Boston Medical Center we identified four trauma diagnoses that we believed to be amenable to the design and implementation of clinical pathways: closed head injury, penetrating wound to the abdomen, penetrating wound to the chest, and penetrating wound to an extremity. Upon implementation of these pathways, appropriate nonoperative, single-system, short-stay trauma patients were enrolled in them. This article details the process by which the four diagnoses were identified and the pathways designed, implemented, and evaluated. Preliminary data demonstrate a significant decrease in resource utilization following implementation of the pathways, without an adverse impact on readmission rates, length of stay, or mortality.

Algorithms↗
PubMedDate not supplied

The role of a clinical pathway in curtailing unnecessary investigations in children with gastroenteritis.

Clinical pathways are useful tools in improving the quality of care of patients treated in hospitals. Gastroenteritis is a short, self-limiting, but common illness of childhood associated with significant costs to the community. The authors assessed the impact of a clinical pathway on investigation ordering in children with gastroenteritis. A retrospective analysis of 2 cohorts of children was performed before (n=1498) and after (n=1252) the introduction of a clinical pathway. Children admitted to hospital with a diagnosis of gastroenteritis were assessed as to the type of pathology tests ordered. Further outcomes measured were rates of admission, emergency department presentations, average length of stay, and direct costs. Subset analysis was undertaken on the initial cohort of patients who had a full blood count as part of their initial assessment. Full blood count was more likely to be performed prior to the introduction of the pathway(77.1%) than after pathway introduction (66.8%; P<.004). Urine microscopy and culture also was significantly decreased from 56.3% to 40.4% (P<.0005). Median patient costs were reduced from $1228 to $752 following pathway introduction (P<.0001); however, rates of admission were increased from 18.6% to 28.8% (P<.0001). Length of stay decreased but was not statistically significant. Full blood count results in the subset analysis revealed that the measurement of a full blood count had no impact on management. Thus, a clinical pathway contributed to more rational ordering of pathology tests and lowered the costs to a hospital of caring for patients with this common illness.

Child, Preschool↗