Using the Liverpool Care Pathway in a nursing home.
The Liverpool Care Pathway provides evidence-based guidelines relating to the care of dying patients. This article outlines a pilot project to introduce it to a 150-bed BUPA nursing home.
Aged↗
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[Clinical pathways. Time recovery and improvement of quality of care].
The authors describe the real experience the Holy Spirit Hospital had regarding the start of clinical trajectories. The authors highlight the numerous advantages these provide for professionals and patients.
Critical Pathways↗
Development and implementation of a clinical pathway for radical cystectomy and urinary system reconstruction.
A multidisciplinary pathway and patient guide for radical cystectomies is described. Various forms of urinary diversion may be employed after cystectomy for bladder cancer. A clinical pathway for the management of patients undergoing radical cystectomy and urinary diversion or neobladder construction has proved beneficial to patient care, to the nursing and medical staffs, and to the institution.
Critical Pathways↗
A decision pathway for the staged management of foot problems in diabetes mellitus.
This review describes a decision pathway for the conservative management of foot problems in persons with diabetes mellitus. The decision pathway was developed by the Louisiana State University Health Sciences Center Diabetes Foot Program as part of the Statewide Diabetes Disease Management Initiative to standardize foot care in a medically underserved population. The pathway describes the prevention and/or management of foot problems through 5 clinical subpathways: injury prevention, warm swollen foot, ulcer, osteomyelitis, and remodeling. The pathway provides physiatrists and other rehabilitation practitioners with a framework to evaluate and manage neuropathic foot problems in a multidisciplinary setting.
Critical Pathways↗
Care management the right balance of care and management?
In 1990, nursing leadership at St. Peter's Medical Center, realizing a need to be creative in order to meet the cost and quality demands of the ever-changing health care system, developed a case management system model called Care Management. The qualifications for the role and the orientation of the Care Managers is describes changes in the program. Innovative programs integrated into the model include patient pathways, workers' compensation care management, and ambulatory care management. Outcomes described include length stay and cost reductions. Future direction of the program in the continuum of care is reviewed.
Academic Medical Centers↗
Medical outcomes assessment and management with emphasis on laboratory applications.
Outcomes assessment and management are playing an increasing role in reducing costs and providing better customer satisfaction. In this overview we describe some outcomes applications and techniques, including benchmarking and clinical pathways. Some outcomes undertakings are complicated and may be frustrating, but most are rewarding to patients or health care providers or both. Challenges are discussed and laboratory applications featured.
Benchmarking↗
The novel SAM domain protein Aveugle is required for Raf activation in the Drosophila EGF receptor signaling pathway.
Activation of the Raf kinase by GTP-bound Ras is a poorly understood step in receptor tyrosine kinase signaling pathways. One such pathway, the epidermal growth factor receptor (EGFR) pathway, is critical for cell differentiation, survival, and cell cycle regulation in many systems, including the Drosophila eye. We have identified a mutation in a novel gene, aveugle, based on its requirement for normal photoreceptor differentiation. The phenotypes of aveugle mutant cells in the eye and wing imaginal discs resemble those caused by reduction of EGFR pathway function. We show that aveugle is required between ras and raf for EGFR signaling in the eye and for mitogen-activated protein kinase phosphorylation in cell culture. aveugle encodes a small protein with a sterile alpha motif (SAM) domain that can physically interact with the scaffold protein connector enhancer of Ksr (Cnk). We propose that Aveugle acts together with Cnk to promote Raf activation, perhaps by recruiting an activating kinase.
Adaptor Proteins, Signal Transducing↗
Success and shortcomings of a clinical care pathway in the management of acute nonvariceal upper gastrointestinal bleeding.
OBJECTIVES: Acute nonvariceal upper gastrointestinal (GI) bleeding is the most common medical emergency encountered by gastroenterologists resulting in high patient morbidity and cost. We sought to establish if a GI bleeding clinical care pathway could improve the quality and cost effectiveness of inpatient medical care. METHODS: A disease management program for acute upper GI bleeding was established. Length of stay, time to endoscopy, utilization of potentially unnecessary radiological tests, acid suppression, and cost of care were compared between patients pre- and postinitiation of GI bleeding pathway guidelines. RESULTS: The instituted GI bleeding management program significantly reduced the use of intravenous H2-blockade from 65.3% to 47.7% (p = 0.002). The use of radiological tests, time to endoscopy, and length of hospital of stay were unchanged. There was a trend toward a reduction in total cost and variable direct cost per patient admitted with acute upper GI bleeding, from $5,381 to $4,627 and from $2,269 to $1,952, respectively. CONCLUSION: A clinical care pathway may affect the management of acute upper GI bleeding and reduce costs. However, there are significant limitations and barriers to the overall effectiveness of such a pathway in actual clinical practice.
Acute Disease↗
CABG path yields savings, but proves 'user unfriendly'.
By reformatting their cardiac surgery pathways and soliciting greater staff participation in the development process, case managers at Bakersfield (CA) Memorial Hospital have boosted staff buy-in and streamlined documentation. Such an overhaul was made necessary last year when the percentage of cardiac patients being put on the pathway dropped sharply, from an initial high of 90% to less than 40%. Under the pathway, extubation times following surgery dropped from an average of 18 hours to 11 hours, with 60% of patients averaging between five and seven hours.
California↗
[Electronic clinical pathway for community acquired pneumonia (e-CP CAP)].
Clinical pathway is a useful strategy for the management of risk and cost for medical care. We developed an electronic clinical pathway (e-CP) for community acquired pneumonia (CAP). We programmed all medical procedures, including physical and laboratory examinations, medical care, prescriptions, diets, limitations of activities, and patient education on a computer. With e-CP, we achieved 30% cost reduction (34048 points vs. 24338 points), 25% shortening of admission duration (10.77 days vs. 8.03 days) and 21% shortening of the duration of intravenous antibiotics administration (8.22 days vs. 6.47 days). Introduction of computer-aided clinical pathway for CAP may contribute to the standardization of medical care for patients with CAP.
Adult↗
Home health care. Clinical pathways and quality integration.
Though clinical pathways in home health care facilitate monitoring of patients' progress and use of resources, literature on home health care is scant. This article shows how quality integration is incorporated into pathways by developing the outcomes, with contributions from both clinical team and patient. Variances in a pathway, caused by either clinician or patient, can identify trends and problems that can be addressed by staff, either through patient education or changes in policy and procedures.
Chronic Disease↗
Impact of a pediatric asthma clinical pathway on hospital cost and length of stay.
This study sought to determine if a clinical pathway developed and executed by specialists in pediatric asthma would reduce hospital costs and length of stay (LOS). The study design was a retrospective, nonrandomized, controlled trial. Subjects were children aged 2-18 years (N = 1,004) with a history of recurrent wheezing, hospitalized with a diagnosis of acute asthma exacerbation between 1995-1998 at the New York Hospital-Weill Cornell Medical Center and treated via the pathway, as well as a control group of 206 children ages 2-18 hospitalized for acute asthma exacerbation in 1994, the year prior to pathway implementation. Patients were treated via the pathway under the supervision of an asthma specialist. The pathway provided guidelines for: 1) frequency of patient assessment; 2) bronchodilator usage; 3) corticosteroid use; 4) laboratory evaluation; 5) vital signs, oxygen saturation, and peak flow measurements; 6) chest x-rays; 7) social work intervention; and 8) discharge planning. The main outcome measures were hospital length of stay, cost per hospitalization, nursing, medication, laboratory and radiology costs, and relapse rate. Total charges for admission and average LOS for 1995-1998 were calculated, and compared with 1994, the year preceding implementation of the pathway. LOS decreased from 4.2 days to 2.7 days (P < 0.0001). The annual total charges for pediatric asthma admissions decreased from 2 million dollars to 1.4 million dollars (P < 0.005). Nursing and laboratory costs showed a statistically significant decrease. Follow-up study at 8 months showed a readmission rate of 0.02%. The implementation of a pediatric asthma clinical pathway, directed by specialists, resulted in significantly decreased length of stay and overall cost, without an increased rate of readmission.
Adolescent↗
Improvements in health care for patients undergoing thyroidectomy.
OBJECTIVE: In this study, we evaluated the effect on cost and clinical outcome of the implementation of departmental subspecialization and a clinical care pathway for patients undergoing thyroidectomy. METHODS: Subspecialization and a clinical thyroidectomy pathway were implemented in 2001 at the Department of Surgery, National University Hospital, Singapore. A total of 150 patients (Group A) who served as controls were compared with 143 patients who were managed after implementation of subspecialization and the clinical thyroidectomy pathway (Group B). Length of stay, postoperative complications and cost per patient were compared between the two groups. RESULTS: The mean age was 46 years and females comprised 77% of all patients. The mean length of hospital stay was shorter in Group B (1.9 days) compared with Group A (3.3 days; p < 0.001). The mean hospital charges also fell significantly after implementation, at 3,524 dollars per patient in Group B compared with 3,929 dollars in Group A (p = 0.003). There was no difference in morbidity between the two groups (2.0% and 1.4% in Groups A and B, respectively). CONCLUSION: This study confirms that length of hospital stay and hospital costs are effectively reduced through the combination of subspecialization and a clinical pathway for patients undergoing thyroidectomy. Subspecialty units and pathways reduce variation in patient care. This effectively leads to better-quality outcomes, more efficient discharge planning and improved cost-effectiveness of clinical services.
Cost-Benefit Analysis↗
Cortico-basal ganglia circuit mechanism for a decision threshold in reaction time tasks.
Growing evidence from primate neurophysiology and modeling indicates that in reaction time tasks, a perceptual choice is made when the firing rate of a selective cortical neural population reaches a threshold. This raises two questions: what is the neural substrate of the threshold and how can it be adaptively tuned according to behavioral demands? Using a biophysically based network model of spiking neurons, we show that local dynamics in the superior colliculus gives rise to an all-or-none burst response that signals threshold crossing in upstream cortical neurons. Furthermore, the threshold level depends only weakly on the efficacy of the cortico-collicular pathway. In contrast, the threshold and the rate of reward harvest are sensitive to, and hence can be optimally tuned by, the strength of cortico-striatal synapses, which are known to be modifiable by dopamine-dependent plasticity. Our model provides a framework to describe the main computational steps in a reaction time task and suggests that separate brain pathways are critical to the detection and adjustment of a decision threshold.
Action Potentials↗
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↗
Defensible documentation using the endoscopy pathway.
Complete, defensible documentation in a busy endoscopy unit can be elusive. Quick turnaround time, impatient physicians, and add-on and emergent cases all contribute to chaotic days. The endoscopy pathway provides a guided path for succinct documentation by the healthcare worker. A scoring system is initiated on admission. Assessment parameters clearly define scores for vital signs, level of consciousness, abdominal status, pain, safety, and mobility. Scores can be scanned quickly and compared by the nurse to identify significant changes in each patient. Documentation is timely, communicative, and complete. The endoscopy pathway is illustrated by a case study. It reflects patients' progress throughout their stay in the GI unit from admission to discharge. The implementation process of this innovative chart form is presented.
Critical Pathways↗
Revision total hip arthroplasty: hospital cost and reimbursement analysis.
Revision total hip arthroplasty is a complex surgical procedure that frequently requires high levels of hospital resources. The purpose of the current study was to report the actual costs and reimbursement to the hospital for a stratified group of patients having revision total hip arthroplasty based on a severity index. The clinical and financial records of 49 patients (51 hips) stratified by complexity of revision were reviewed. Clinical variable included age, length of stay, operating time, estimated blood loss, number of transfusions, implant type, metallic augmentation, use of bone graft, and time spent in the postanesthesia care unit. Financial review included the actual fixed and variable costs associated with each procedure. Hospital costs associated with revision total hip arthroplasty were significantly greater in the most complex revisions and in older patients. The use of bone grafting techniques on the femur resulted in significantly greater costs. The average loss to the hospital was $5402 US dollars per procedure with a range of $5657 (US dollars) profit to $28,780 (US dollars) loss. Procedures in patients younger than 65 years has an average loss of $1133 US dollars. All procedures in patients who were 65 years or older resulted in a loss to the hospital, with the average loss being $8617 US dollars. Despite improvements in length of stay, use of clinical pathways, and negotiated discounts on implants, the hospital loss on each hip revision procedure averaged $5402 US dollars.
Adult↗
Care pathways in obstetrics: the effectiveness in reducing the incidence of episiotomy in childbirth.
AIM: To develop a care pathway for childbirth. BACKGROUND: Care pathways are emerging as an effective tool to improve clinical and organizational performance. METHODS: A pre- and postimplementation analysis model was used to evaluate the effect of introducing a care pathway for childbirth. Key outcome indicators and costs were reviewed to compare the traditional care processes with those of the care pathway. The study involved 380 women. RESULTS: There was a significant reduction in episiotomy rate (from 14.90% to 8.6%, P = 0.02) in patients being cared for using a care pathway approach; however, there were no differences in caesarean section and in perineal wound rates. The average costs per patient on the care pathway were euro 1278.42 ( pound 873.64) compared with euro 1,146.87 ( pound 783.74) preimplementation. The study also demon- strated an increase in patient satisfaction for women cared for using the care pathway approach. CONCLUSIONS: The care pathway proved to be a valid methodological approach to childbirth, allowing healthcare workers to efficiently share the care of the women, guaranteeing safe and effective care.
Adult↗