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At least 1,657 records · Page 92Linked to original sources
PubMed2006

Using a clinical pathway and education to reduce inappropriate prescribing of enoxaparin in patients with acute coronary syndromes: a controlled study.

AIMS: To evaluate efficacy of a pathway-based quality improvement intervention on appropriate prescribing of the low molecular weight heparin, enoxaparin, in patients with varying risk categories of acute coronary syndrome (ACS). METHODS: Rates of enoxaparin use retrospectively evaluated before and after pathway implementation at an intervention hospital were compared to concurrent control patients at a control hospital; both were community hospitals in south-east Queensland. The study population was a group of randomly selected patients (n = 439) admitted to study hospitals with a discharge diagnosis of chest pain, angina, or myocardial infarction, and stratified into high, intermediate, low-risk ACS or non-cardiac chest pain: 146 intervention patients (September-November 2003), 147 historical controls (August-December 2001) at the intervention hospital; 146 concurrent controls (September-November 2003) at the control hospital. Interventions were active implementation of a user-modified clinical pathway coupled with an iterative education programme to medical staff versus passive distribution of a similar pathway without user modification or targeted education. Outcome measures were rates of appropriate enoxaparin use in high-risk ACS patients and rates of inappropriate use in intermediate and low-risk patients. RESULTS: Appropriate use of enoxaparin in high-risk ACS patients was above 90% in all patient groups. Inappropriate use of enoxaparin was significantly reduced as a result of pathway use in intermediate risk (9% intervention patients vs 75% historical controls vs 45% concurrent controls) and low-risk patients (9% vs 62% vs 41%; P < 0.001 for all comparisons). Pathway use was associated with a 3.5-fold (95% CI: 1.3-9.1; P = 0.012) increase in appropriate use of enoxaparin across all patient groups. CONCLUSION: Active implementation of an acute chest pain pathway combined with continuous education reduced inappropriate use of enoxaparin in patients presenting with intermediate or low-risk ACS.

Angina, Unstable↗
PubMedDate not supplied

Expanding student learning using patient pathways.

This article examines the first stages of a project to address problems in the quality of students' clinical experience after consultation with senior nurses at a large district general hospital. The term 'placement pathway' is defined and the use of these pathways is discussed. Several examples are given to demonstrate ways in which students can gain a wider understanding of the care of the patient throughout their stay and still achieve competence.

Clinical Competence↗
PubMedDate not supplied

Automated clinical pathways in the patient record legal implications.

Nurses have long been taught the need for precise documentation of patient care. Yet, as demands on nurses' time increases, maintaining an accurate and informative patient record becomes more difficult. The use of an automated clinical pathway that contains both the plan of care and a record of the care, while increasing communication between the care providers, is a promising solution to the problem. In this article, the process of moving a clinical pathway from paper to a computerized format is discussed. Legal issues related to its status as a permanent part of the patient record are considered. The legal implications of the pathway as a standard of care are also examined. As clinical pathways and computers merge, effective automated plans of care that also can serve as a documentation tool will benefit both the caregiver and the patient, while decreasing the risk of liability.

Arizona↗
PubMedDate not supplied

Case management in Australia: application of Moxley's scenarios.

In 1989 David Moxley produced a text for generic case management in the human services. He has revisited his initial work and argues that the case management concept has taken on diverse meaning as it has been applied more widely and for very different agendas. It may have emerged in community care, but is now being utilised as a tool of restructuring in all arenas of service provision. Moxley now suggests five distinct scenarios for the future of case management: community support and the organisation of support systems for people with disabilities; management of the economic costs of human services; the management of undesirables; the management of clinical pathways; recipient management services. His commentary is based on his U.S. experience. This article will examine the relevance of his predictions to the Australian context.

Australia↗
PubMed2003

'Toothache stories': a qualitative investigation of why and how people seek emergency dental care.

OBJECTIVE: To understand from the patient's perspective the types of dental problem which present at weekends, how they affect people, and the care-seeking behaviour of emergency dental patients. BASIC DESIGN: Consecutive patients attending two emergency dental clinics at weekends were interviewed prior to seeing the dentist. The audio-recorded interview transcripts were analysed using the "framework" method of applied qualitative data analysis. SETTING: A community-based and a dental hospital emergency dental clinic. SUBJECTS: 44 emergency dental patients. RESULTS: Pain was the main presenting symptom, a key domain of quality of life and the underlying cause of most other quality of life effects. However, for patients deciding what symptoms mean--crucially whether they mean they need to see a dentist urgently--a wide range of other contextual factors come into play. These go beyond the individual patient's recent and current perception of symptom intensity. They encompass past experience of similar symptoms, past care-seeking experiences, anticipated effects on quality of life, anticipated service availability, joint decision-making and lay information from family and friends, professional opinions from non-dentists, expectations concerning what work dentists should do, and what symptoms distinguish "simple toothache" from more serious problems. CONCLUSIONS: The effects of, and meanings which people attach to, acute dental symptoms are complex. Combined with poor awareness of the existence of emergency dental services it is not surprising that patients' pathways to care are correspondingly complicated. The planning of emergency dental services should be based on a broader, patient-derived understanding of the need for them.

Adolescent↗
PubMed1999

Cooperation of p38 and extracellular signal-regulated kinase mitogen-activated protein kinase pathways during granulocyte colony-stimulating factor-induced hemopoietic cell proliferation.

Hemopoietic cytokines such as interleukin-3 and granulocyte colony-stimulating factor (G-CSF) are potent activators of hemopoietic cell growth and strongly induce activation of extracellular signal-regulated kinase (ERK), c-Jun-N-terminal kinase (JNK), and p38 mitogen-activated protein (MAP) kinases. However, the role of these kinases is unclear. Using specific chemical inhibitors for MEK and p38, we demonstrate here that both ERK and p38 pathways are critically involved in the transduction of a proliferative signal and cooperate in G-CSF-induced cell proliferation. We show that, like ERK and JNK activation, activation of p38 and its downstream substrate MAP kinase-activated protein kinase 2 by interleukin-3 or G-CSF requires Ras activation. We demonstrate that two distinct cytoplasmic regions of the G-CSF receptor are involved in activation of the p38 pathway: a region within the 100 membrane-proximal amino acids is sufficient to induce low levels of p38 and MAP kinase-activated protein kinase 2 activation, whereas the membrane-distal phosphorylation site Tyr763 mediates strong activation of these kinases. The levels of p38 activation correlate closely with those of Ras activation by G-CSF, suggesting that the degree of Ras activation is a critical determinant for the extent of p38 activation by hemopoietic cytokines.

Animals↗
PubMed2004

Fyn kinase modulates synaptotoxicity, but not aberrant sprouting, in human amyloid precursor protein transgenic mice.

Alzheimer's disease (AD), the most common neurodegenerative disorder, results in progressive degeneration of synapses and aberrant sprouting of axon terminals. The mechanisms underlying these seemingly opposing cellular phenomena are unclear. We hypothesized that Fyn kinase may play a role in one or both of these processes because it is increased in AD brains and because it is involved in synaptic plasticity and axonal outgrowth. We investigated the effects of Fyn on AD-related synaptotoxicity and aberrant axonal sprouting by ablating or overexpressing Fyn in human amyloid precursor protein (hAPP) transgenic mice. On the fyn+/+ background, hAPP/amyloid beta peptide (Abeta) decreased hippocampal levels of synaptophysin-immunoreactive presynaptic terminals (SIPTs), consistent with previous findings. On the fyn-/- background, hAPP/Abeta did not affect SIPTs. SIPT reductions correlated with hippocampal Abeta levels in hAPP/fyn+/+, but not hAPP/fyn-/-, mice suggesting that Fyn provides a critical link between hAPP/Abeta and SIPTs. Furthermore, overexpression of Fyn exacerbated SIPT reductions in hAPP mice. We also found that the susceptibility of mice to hAPP/Abeta-induced premature mortality was decreased by Fyn ablation and increased by Fyn overexpression. In contrast, axonal sprouting in the hippocampus of hAPP mice was unaffected. We conclude that Fyn-dependent pathways are critical in AD-related synaptotoxicity and that the pathogenesis of hAPP/Abeta-induced neuronal alterations may be mechanistically heterogenous.

Alzheimer Disease↗
PubMed2006

Clinical pathways development and computer support in the EPR: lessons learned.

This paper refers to a project for development and optimization of a clinical pathway for the Lumbar Nerve Root Compression Syndrome. A special focus is taken on computer support for pathway development and implementation. An innovative combination of "rapid prototyping" of a workflow model and a 2 level approach using round robin methods in a large group and individual semi-structured interviews is presented. The method focuses on process optimization instead of process modeling and concentrates on areas of the workflow which may be optimized. Critical parts of the optimized clinical workflow have been implemented inside a commercial electronic patient record system.

Critical Pathways↗
PubMed2003

Impact of a clinical pathway and standardization of treatment for acute appendicitis.

PURPOSE: Acute appendicitis is one of the most common surgical diseases. Simple and precise guidelines for treating acute appendicitis are necessary for improving the treatment outcome of this disease. The purpose of this study was to determine the impact of a clinical pathway and standardization of treatment for acute appendicitis at our hospital. METHODS: The clinical pathway and standardization of treatment for acute appendicitis were introduced to our hospital in January 2000. We compared the length of hospitalization, postoperative stay, hospital costs, and operation time during the years before and the years after their introduction. RESULTS: There was no significant difference in the clinical characteristics of the 73 patients in the control group and the 112 patients in the pathway group. There were 6 (8.2%) and 24 (21.4%) cases of perforated appendicitis in the respective groups. The mean length of hospitalization ( P < 0.001), postoperative stay ( P < 0.001), and hospital costs ( P < 0.01) were significantly less in the patients in the pathway group who underwent surgery. CONCLUSION: Our clinical pathway and standardization of treatment for acute appendicitis proved effective for treating patients with acute appendicitis and minimizing costs without compromising patient care.

Acute Disease↗
PubMed2005

Barriers to the use of outpatient enoxaparin therapy in patients with deep venous thrombosis.

OBJECTIVE: To establish a clinical pathway for outpatient enoxaparin therapy in deep venous thrombosis (DVT) and then characterize its implementation and barriers to use. PROCEDURE: Single institution, prospective, observational study of consecutive adult emergency department patients (age > or =18 years) who had a diagnosis of DVT. A clinical pathway was created to facilitate outpatient therapy with enoxaparin, and then all patients with DVT were enrolled and studied. RESULTS: A total of 97/98 (99%) eligible patients were enrolled. Among 97 patients, 29 (30%) were successfully started on the outpatient enoxaparin therapy approach. Of the 68 (70%) patients not started on the outpatient therapy, 19 (20%) patients had contraindications to anticoagulant therapy, 33 (34%) had other indications for hospitalization, 6 (6%) were unable to reliably self-inject, and 10 (10%) patients had a primary care physician or emergency physician who rejected the outpatient approach. CONCLUSIONS: The establishment of an organized DVT pathway for outpatient enoxaparin may facilitate home therapy; however, there will remain reasons that make hospital admission unavoidable in some patients.

Ambulatory Care↗
PubMed1997

Utility of clinical pathway and prospective case management to achieve cost and hospital stay reduction for aortic aneurysm surgery at a tertiary care hospital.

PURPOSE: We reviewed our experience with a clinical pathway instituted in December 1993 for all nonurgent abdominal aortic aneurysm (AAA) surgery. METHODS: We analyzed a reference group of 49 consecutive pre-pathway AAA patients (group I) and the 44 patients enrolled in the first year of the pathway (group II). On the basis of the interim review of data collected during the first year, pathway modifications were made, and 34 patients enrolled after these modifications (group III) were also analyzed. RESULTS: Comparison of groups I and II showed that institution of the pathway resulted in a marginally significant reduction in mean charges of 14.7% (p = 0.09), and a slight fall in mean length of stay (LOS) (13.8 vs 13.1 days, NS) and mortality rate (4.1% vs 2.3%, NS). For group II, a significant correlate (p < 0.05) of increased charges was fluid overload as diagnosed by chest radiograph. This recognition led to active efforts to reduce perioperative fluid administration. Comparison of groups II and III revealed that the practice modifications led to marked reduction in the incidence of fluid overload (73% vs 24%; p < 0.01), mean charges (30.4% reduction; p < 0.05), mean LOS (13.1 vs 10.2 days; p < 0.05), and median LOS (11 vs 8 days). Multiple regression analysis of all pathway patients showed that preoperative renal insufficiency is a significant predictor of both increased LOS (p < 0.01) and charges (p < 0.01), but that age, sex, and coronary disease were not predictive. Of the postoperative parameters analyzed, important correlates of increased charges were acute renal failure (p < 0.01) and fluid overload (p < 0.01). CONCLUSIONS: Institution of a clinical pathway for AAA repair resulted in significant charge reduction and a slight reduction in stay. Practice modifications based on interim data analysis yielded further significant reductions in charges and LOS, with overall per-patient charge savings (group I vs III) of 40.6% (p < 0.05) and overall LOS reduction of 3.5 days (p < 0.05). The reduction in actual charges was seen despite an overall increase in the hospital rate structure. Comparing groups I, II, and III, we found no indication of increasing mortality rate. Ongoing analysis has identified correlates of increased charges, potentially permitting identification of high-cost subgroups and more focused cost-control efforts. Rather than restricting management, clinical pathways with periodic data analysis may improve quality of care.

Aortic Aneurysm, Abdominal↗
PubMed2002

[First experiences with clinical pathways in carotid surgery].

The introduction of guidelines for carotid surgery into praxis. Early experiences with the clinical pathway. With the use of DRG's for reimbursements, a new organization of clinical pathways may play an increasingly important role in the delivery of health care. The impact of clinical pathways as a management tool in the treatment of patients with carotid occlusive disease was studied. Representatives of all involved disciplines identified in which sequence, where, when, by whom and which care a patient with carotid disease should receive. The individual steps of care were analysed, estimating their utility and determining a new plan for a patient's care. The clinical pathway specifies a target time window, defining exactly the internal and external logistics. The early experiences demonstrate that clinical pathways can be a useful tool for improving the quality of health care by improving cost and process transparency. Hospital length of stay was reduced by 2.3 days.

Carotid Stenosis↗
PubMed2001

Outpatient treatment of deep venous thrombosis: a clinical care pathway managed by the emergency department.

STUDY OBJECTIVE: We evaluate the effectiveness and safety of an outpatient clinical care pathway for the initial treatment of acute proximal lower-extremity deep venous thrombosis (DVT) with low molecular weight heparin (LMWH) managed by the emergency department of 2 affiliated community hospitals. METHODS: This observational, retrospectively defined, population-based study with 39(1/2) months of preintervention analysis and 32(1/2) months of postintervention analysis was conducted in 2 suburban EDs of a large group model health maintenance organization. Our outpatient DVT clinical care pathway used careful patient selection and multidisciplinary follow-up. Ninety-six patients before the intervention and 178 patients after the intervention met eligibility criteria for the pathway. Adverse events during the first 2 weeks of treatment included symptomatic pulmonary embolism (PE), progressive DVT, minor and major bleeding, and death. RESULTS: Demographic and baseline clinical characteristics of the 2 groups were similar. Five (5.2%) of 96 preintervention subjects (95% confidence interval [CI] 2.4 to 8.1) developed adverse events compared with 5 (2.8%) of 178 postintervention subjects (95% CI 1.5 to 4.1; difference between groups 2.4%; P =.50). In each group, 1 (1.0% versus 0.6%) subject developed a PE, 2 (2.1% versus 1.1%) developed progressive symptoms of progressive DVT, and 2 (2.1% versus 1.1%) developed minor bleeding. Major bleeding occurred in 1 (1.0%) preintervention subject and no postintervention subjects. No patient in either cohort died. CONCLUSION: Managed by the ED, an outpatient DVT clinical care pathway using careful patient selection and an integrated multidisciplinary approach can provide a similar degree of effectiveness and safety as customary inpatient therapy.

Adolescent↗
PubMedDate not supplied

Guidelines for evaluating tools for clinical decision making.

Managed care is designed to reduce healthcare costs by controlling use of services and by improving quality outcomes. Preparation of nurses to practice in a health management environment mandates clear understanding of this new environment Nursing educators should focus on the spectrum of health services and enhance the nurses'ability to assess patients independently, implement health plans, and be responsible for outcomes. Nurses must understand how clinical decision-making tools facilitate planning care to maximize use of resources. The authors describe the construction and evaluation of a learning strategy that involves the use of guidelines to evaluate clinical decision-making tools. Two examples are presented: evaluating clinical pathways in a case management project and evaluating algorithm (practice guideline) outcome data from a prenatal population case study from a local health maintenance organization.

Algorithms↗
PubMed2000

Emergi-paths and stroke teams: an emergency department approach to acute ischemic stroke.

In patients with early acute ischemic stroke (AIS), studies have shown improved recovery rates when thrombolytic therapy is appropriately initiated. However, in clinical practice, there are several barriers to rapid patient evaluation and drug administration. To facilitate the management of this population, an AIS clinical pathway, Emergi-path, was developed. Initiated at the time of the patients' arrival to the emergency department, Emergi-path provides a step-by-step guide for early care of AIS patients. A citywide stroke team plays an integral role in this process by responding to stroke codes. Implementation of an AIS pathway and activation of an organized team of stroke specialists can facilitate rapid evaluation and treatment of this high-risk population.

Aged↗
PubMedDate not supplied

Contraction of myofibroblasts in granulation tissue is dependent on Rho/Rho kinase/myosin light chain phosphatase activity.

During wound healing and fibrocontractive diseases fibroblasts acquire a smooth muscle cell-like phenotype by differentiating into contractile force generating myofibroblasts. We examined whether regulation of myofibroblast contraction in granulation tissue is dominated by Ca2+-induced phosphorylation of myosin light chain kinase or by Rho/Rho kinase (ROCK)-mediated inhibition of myosin light chain phosphatase, similar to that of cultured myofibroblasts. Strips of granulation tissue obtained from rat granuloma pouches were stimulated with endothelin-1 (ET-1), serotonin, and angiotensin-II and isometric force generation was measured. We here investigated ET-1 in depth, because it was the only agonist that produced a long-lasting and strong response. The ROCK inhibitor Y27632 completely inhibited ET-1-promoted contraction and the phosphatase inhibitor calyculin elicited contraction in the absence of any other agonists, suggesting that activation of the Rho/ROCK/myosn light chain phosphatase pathway is critical in regulating in vivo myofibroblast contraction. Membrane depolarization with K+ also stimulated a long-lasting contraction of granulation tissue; however, the amount of force generated was significantly less compared to ET-1. Moreover, K+-induced contraction was inhibited by Y27632. These results are consistent with inhibition of myosin light chain phosphatase by the Rho/ROCK signaling pathway, which would account for the long-duration contraction of myofibroblasts necessary for wound closure.

Amides↗
PubMed2004

Expression of costimulatory molecules (4-1BBL and Fas) and major histocompatibility class I chain-related A (MICA) in aortic tissue with Takayasu's arteritis.

To further investigate the immunological mechanisms involved, we analyzed the expression of costimulatory molecules in aortic tissue and their counterpart molecules on infiltrating cells of patients with Takayasu's arteritis. We also examined the expression of major histocompatibility complex (MHC) class I chain-related (MIC) A in aortic tissue, which is known to be induced by external stress, and its counterpart NKG2D receptors on infiltrating cells. Among these costimulatory molecules, strong expression of 4-1BBL and Fas was induced in the aortic tissue, and most of the infiltrating cells expressed 4-1BB and FasL, suggesting these pathways play critical roles in T-cell-mediated vascular injury. We also found that MICA was strongly induced in the aortic tissue and that at least part of the infiltrating cells expressed NKG2D receptors. Some infiltrating cells - but not vascular smooth muscle cells - seemed to have undergone apoptosis. Our findings strongly suggest that 4-1BB/4-1BBL and Fas/FasL pathways play important roles in vascular injury in Takayasu's arteritis. We assume that gammadelta T cells infiltrated aortic tissue recognizing MICA, resulting in the induction of MHC antigens and costimulatory molecules, and then alphabeta T-cells infiltrated recognizing some auto-antigens presented by MHC antigens, leading to chronic inflammation.

4-1BB Ligand↗
PubMed1999

Predictors of QoL in renal transplant recipients: bridging the gap between research and clinical practice. Posttransplant Quality of Life Intervention Study Group.

Previous research in quality of life (QoL) in renal transplant recipients has identified three factors predictive of improved QoL: reduction in adverse events, facilitation of employment, and enhancement of social support. After a decade of QoL outcome research, the researchers have proposed a multidisciplinary approach to posttransplant care by developing a clinical pathway using the three predictive factors. Putting into practice the research outcome, this pathway systematically addresses and evaluates each of the study arms and the impact on QoL. A clinical team has been instrumental in developing a model of practice that incorporates the research outcomes.

Critical Pathways↗