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Two hospitals--one community and one urban--use clinical pathways to streamline patient care. They lower the average length of stay by 41% and 30%, respectively, and shrink clinical and surgical complications.
The transforming growth factor-beta (TGF-beta) and Wnt/wingless pathways play critical roles in the specification of cell fate during development and also contribute to cancer formation and progression. Whereas Wnt signaling is clearly pro-oncogenic, TGF-beta signaling is cell- and context-dependent, manifesting both inhibitory and proliferative effects. The growth factor, gastrin, has previously been shown to be a downstream target of the Wnt pathway and a promoter of gastrointestinal cancer. In this study, we show that the mouse gastrin promoter is regulated synergistically by TGF-beta/Smads and beta-catenin/T-cell factor (TCF). Co-transfection of Smad3/Smad4 and beta-catenin expression constructs synergistically activated mouse gastrin promoter activity 30-60-fold in AGS cells with minimal effect seen with either construct alone. This activation was further potentiated by TGF-beta1 treatment. Mutating either the TCF binding site or the Smad-binding element (SBE) diminished the activation of gastrin expression by Smad3/Smad4 and beta-catenin and led to a loss of gastrin promoter responsiveness to TGF-beta1 treatment. Wnt and TGF-beta regulated endogenous gastrin mRNA levels in AGS cells in a similar fashion, as revealed by small interference RNA studies or overexpression of Smads and TCF4/beta-catenin. Electrophoretic mobility shift assays and DNA affinity precipitation assays showed that the putative SBE and T-cell factor (TCF) sites were able to bind a complex containing Smads and beta-catenin/TCF4. In addition, the synergy between Smads and beta-catenin/TCF4 was dependent on CREB-binding protein (CBP)/P300, as demonstrated by overexpression of CBP or E1A. Moreover, by using a heterogeneous promoter reporter system, we showed that this complex containing Smads/TCF4/beta-catenin complex was able to up-regulate transcription at isolated SBE or TCF sites. Thus, the Wnt signaling pathway is able to activate some target genes through its actions as a co-activator at non-TCF sites and has the potential to profoundly alter transcriptional responses to TGF-beta signaling.
Hospital utilization data for communities with high levels of managed care penetration can be readily used to develop utilization benchmarks in any proactive efforts to prepare for oncoming prospective pricing system (PPS) initiatives. In a cooperative effort among all four Syracuse, NY hospitals, the combined average hospital LOS for one surgical and three medical DRGs was compared with benchmarks derived from similar populations in three heavily managed care-penetrated west coast communities. Implementation of clinical or critical paths are a widely accepted approach to shortening hospital lengths of stay and improving both resource usage and clinical outcomes. After implementing clinical paths across all four institutions and revisiting their data a year later, a fairly dramatic reduction (28%) in mean LOS for total hip replacement procedures was achieved. Two of the three medical DRGs, stroke and acute MI, each showed a mean reduction of 17% in LOS.
OBJECTIVES: This paper examines the utility and sustainability of a clinical pathway for treating nursing home residents with pneumonia from the perspective of nursing administrators and medical directors in Ontario, Canada. The discussion includes a comparison of the perspectives of the administrators and the nursing staff (reported in part I of this article). DESIGN: A qualitative case study design was used. SETTING: Data were collected from 6 nursing homes in Southern Ontario that were drawn from a larger randomized controlled trial of a clinical pathway to help identify, diagnose, and manage cases of nursing home-acquired pneumonia. PARTICIPANTS: Six interviews were conducted with nursing administrators and 2 with medical directors (1 per facility). Key themes were identified in the interview data using the template style of analysis described by Miller and Crabtree. FINDINGS: Administrators were in favor of using a clinical pathway for identifying and treating pneumonia in nursing home residents. Participants thought that during the study residents with pneumonia received better and more timely care, and that nurses' clinical skills, knowledge, and confidence had improved. In comparison with views expressed by nurses and medical directors in the same facilities, nursing administrators tended to report less clinical training and staff support were required to successfully implement the pathway. CONCLUSIONS: Even though nurses and administrators strongly support the use of a pneumonia clinical pathway in nursing homes, implementation plans should be tailored to individual facilities and be informed by the perspectives of both administrators and staff.
Historically, patients undergoing a lumbar laminectomy for discectomy (LLD) have been admitted to the hospital for 1 to 3 days. Because a patient undergoing a surgical procedure is not necessarily medically ill, many surgical procedures are now performed on an outpatient basis. A multidisciplinary nursing team proposed that some patients scheduled to undergo an LLD would be able to have this surgery as an outpatient. A 6-month research project was developed to study outcomes of patients undergoing LLD who were discharged after 4 to 6 hours of postoperative care in the PACU. Guidelines were established to define the candidates for enrollment in the same day LLD. A patient clinical pathway was established, and outcome monitors were selected. Twenty-seven patients were enrolled in this study. This article describes the process of development, application, and future implications of this study.
Systemic or intracerebral administration of glucocorticoids modulates memory consolidation in several tasks. Previously, we have shown that these memory-modulatory effects depend on an intact basolateral complex of the amygdala (BLC) and efferents from the BLC that run through the stria terminalis. It is currently unknown, however, what BLC efferent structures mediate these effects. The present experiments were designed to determine whether the nucleus accumbens (NA), which receives BLC efferents through the stria terminalis and is involved in several BLC-dependent behaviours, is involved in glucocorticoid-induced modulation of memory consolidation. In experiment 1, rats with bilateral sham or N-methyl-D-aspartate (NMDA)-induced lesions of the NA were trained on a one-trial, footshock-motivated inhibitory avoidance task, and given immediate post-training injections of either the synthetic glucocorticoid dexamethasone (0.3 or 1.0 mg/kg, s.c.) or vehicle. Testing 48 h later revealed that dexamethasone significantly enhanced retention in sham-lesioned rats but that the enhancing effect was blocked in NA-lesioned rats. An asymmetrical, or crossed-lesion design was employed in experiment 2. Rats with a unilateral NMDA-induced lesion of the BLC and a unilateral lesion of either the ipsilateral or contralateral NA were trained as in experiment 1. Testing 48 h later revealed that dexamethasone enhanced retention in ipsilaterally lesioned rats, but that this effect was blocked in contralaterally lesioned rats. These findings indicate that an intact BLC-NA pathway is critical for the enhancing effects of glucocorticoids on memory consolidation, and are consistent with the view that the BLC regulates memory consolidation in other brain regions.
INTRODUCTION: During World War II, failure to treat penetrating colon injuries with diversion could result in court martial. Based on this wartime experience, colostomy for civilian colon wounds became the standard of care for the next 4 decades. Previous work from our institution demonstrated that primary repair was the optimal management for nondestructive colon wounds. Optimal management of destructive wounds requiring resection remains controversial. To address this issue, we performed a study that demonstrated risk factors (pre or intraoperative transfusion requirement of more than 6 units of packed red blood cells, significant comorbid diseases) that were associated with a suture line failure rate of 14%, and of whom 33% died. Based on these outcomes, a clinical pathway for management of destructive colon wounds was developed. The results of the implementation of this pathway are the focus of this report. METHODS: Patients with penetrating colon injury were identified from the registry of a level I trauma center over a 5-year period. Records were reviewed for demographics, injury characteristics, and outcome. Patients with nondestructive injuries underwent primary repair. Patients with destructive wounds but no comorbidities or large transfusion requirement underwent resection and anastomosis, while patients with destructive wounds and significant medical illness or transfusion requirements of more than 6 units/blood received end colostomy. The current patients (CP) were compared to the previous study (PS) to determine the impact of the clinical pathway. Outcomes examined included colon related mortality and morbidity (suture line leak and abscess). RESULTS: Over a 5.5-year period, 231 patients had penetrating colon wounds. 209 survived more 24 hours and comprise the study population. Primary repair was performed on 153 (73%) patients, and 56 patients had destructive injuries (27%). Of these, 40 (71%) had resection and anastomosis and 16 (29%) had diversion. More destructive injuries were managed in the CP group (27% vs. 19%). Abscess rate was lower in the CP group (27% vs. 37%), as was suture line leak rate (7% vs. 14%). Colon related mortality in the CP group was 5% as compared with 12% in the PS group. CONCLUSIONS: The clinical pathway for destructive colon wound management has improved outcomes as measured by anastomotic leak rates and colon related mortality. The data demonstrated the need for colostomy in the face of shock and comorbidities. Institution of this pathway results in colostomy for only 7% of all colon wounds.
Atrial fibrillation is the most common sustained arrhythmia likely to be encountered in clinical practice. It is associated with significant morbidity and mortality. The treatment of patients with atrial fibrillation can be complex and costly, especially when patients are hospitalized for acute management of this arrhythmia. In this review, we summarize current approaches to the acute management of atrial fibrillation with an emphasis on the most cost-effective approaches. We review acute methods of heart rate control and cardioversion, including pharmacologic and other minimally invasive strategies. We believe that the most cost-effective approaches may require the use of standardized clinical pathways. This may help to ensure that patients with acute atrial fibrillation receive the most effective and efficient care.
BACKGROUND: The usefulness of clinical pathways for the complex trauma patient is unclear. We analyzed the effect of a clinical pathway for severe traumatic brain injury (TBI) on resource utilization. METHODS: A clinical pathway for severe TBI (Glasgow Coma Scale (GCS) score < or = 8 at 24 hours) was developed by a multidisciplinary team and used for all patients with severe TBI. Data were gathered prospectively for 15 months and compared with data from historical controls from the previous year. Patients who survived < 48 hours were excluded. RESULTS: The clinical pathway was used for 84 patients with severe TBI and compared with 49 historical controls. No differences in Injury Severity Scores (27 vs. 27) or GCS scores at 24 hours (6.2 vs. 6.5) existed between control or pathway patients. There was an overall increase in the mortality rate of pathway patients (from 12.2 to 21.4%), but this was entirely attributable to withdrawal of care that was initiated by family members in patients with an average age of 71 years, an average GCS score of 4.7, and an average Injury Severity Score of 29. Among survivors, pathway patients had a significant decrease in ventilator days (11.5 +/- 0.9 vs. 14.6 +/- 1.2; p < 0.05), intensive care unit days (16.7 +/- 1.0 vs. 21.2 +/- 1.4; p < 0.05), and hospital days (23.4 +/- 1.2 vs. 31.0 +/- 3.0; p < 0.05). There were no differences in the incidence of complications or functional outcomes. CONCLUSION: The use of a clinical pathway for severe TBI resulted in a significant reduction in resource utilization. This study suggests that clinical pathways may be a useful component of patient care after blunt trauma.
Numerous studies have demonstrated that a well-designed clinical pathway is an effective means of sustaining quality while controlling costs in the management of certain disease entities. We evaluated the impact that cost and medical quality have on the implementation of a clinical pathway for laparoscopy-assisted vaginal hysterectomy (LAVH). This retrospective study involved a sample of 124 patients who underwent LAVH in a medical center in central Taiwan. Patients were divided into two groups on the basis of whether they received treatment before or after implementation of the LAVH clinical pathway. The preclinical pathway group was comprised of 40 patients who underwent LAVH before clinical pathway implementation (May-December 1997). The clinical pathway group included 84 patients who underwent LAVH after implementation of the clinical pathway (January 1998-March 1999). In order to study the impact of the LAVH clinical pathway, patient characteristics were controlled by multiple linear regression. The results showed a significant reduction in cost, average length of hospital stay, and average duration of surgery and anesthesia (p < 0.01). Dependent nominal variables for clinical indicators like postoperative intravenous fluid and injection of antibiotics 48 h after surgery, and complications were analyzed by a logistic regression model. The results noted better control of antibiotic intravenous injection 48 h after surgery in the clinical pathway group (p = 0.03). The other indicators included delay of operation day, blood transfusion, patient mortality, and patients readmitted within 2 weeks. There was one operation day delay and one readmission within 2 weeks of discharge in the preclinical pathway group. Based on our results, the implementation of a clinical pathway for LAVH contains cost while maintaining quality of care, especially when the medical fees are paid under the case payment system.
In the Department of Obstetrics and Gynecology at our hospital, a team of doctors, pharmacists, nurses, and other medical staff was established to prepare a clinical pathway for laparoscopic cystectomy. Various data on clinical charts including the use of drugs were collected from 57 patients by pharmacists and nurses. Based on the analysis of these data, hospitalization period, method of preoperative bowel preparation, time to initiation of food intake, duration of antibiotic administration, and time and content of pharmaceutical instructions to patients of dosage and administration were determined. Criteria for variances requiring the doctor's directions were determined for fever, wound pain, and vomiting. The clinical pathway established here allows of not only the efficient and uniform care of patients, but also the active exchange of opinions among members of the medical team. Moreover, most patients who replied to a questionnaire said that they were at ease during hospitalization because they had received detailed information about the clinical pathway including the use of drugs before surgery. Thus, the participation of pharmacists on a medical team that is introducing a clinical pathway is particularly important because the use of drugs and pharmaceutical care are an important part of good patient care.
Foot problems may be one of the lesser known complications of diabetes, but they have a major impact on people with the condition. The NHS National Diabetes Support Team has produced a guide to diabetic foot services and this article will look at some of the key areas in diabetic foot care today which are also outlined in the guide. The key areas are: prevention and screening, care pathways, multidisciplinary teams, and workforce and staff skills. Examples of how some of these issues are being tackled in England are featured in the article as case studies.
The Cancer Nursing Strategy (Department of Health (DoH), 2000a) expects nurses at senior level to lead the way in improving the organization and delivery of cancer care. Lack of forward planning can be a feature of community palliative care, and may lead to inappropriate crisis admission in the last days despite patients and relatives expressing a wish to stay at home. This article attempt to demonstrate how, though collaboration and effective team working, issues and/or problems encountered in the last days of life were managed by developing and promoting a care pathway for the last days of life. Although based on Ellershaw's pioneering work, this pathway was developed specifically for use in the community to reflect and address the particular problems encountered in this setting when caring for dying patients.
Case managers at Shepherd Center in Atlanta were satisfied with their procedures regarding inpatient i.v. therapy for multiple sclerosis patients, but they saw an opportunity to further reduce length of stay by implementing a current-practice pathway for MS. Case managers say one reason they were able to secure physician support for the pathway was that they based the path on the center's own best practices. They also formed pathway authorship groups around physician champions. Following a patient's stay at Shepherd, inpatient case managers coordinate care with the center's outpatient clinic as well as with the patient's primary care physician and local hospital.
Medication errors could be contributing to high variance rates and treatment costs for patients placed on your clinical pathways, and you might not even know it, experts say. The problem is potentially severe. One recent study found a 9% error rate in admixtures overall and potentially catastrophic 34.4% to 56.7% error rates for potassium chloride mixtures. However, experts claim that hospitals could go a long way toward solving their admixture error problems by simply switching to ready-to-use products and having nurses record actual medications per day on clinical pathways. Meanwhile, HCFA is about to make official a new ceiling for errors: 2%, vs. the old 5% rate. This could pose serious problems for hospitals dependent on Medicare and Medicaid reimbursements.
With today's emphasis on horizontal and vertical integration of patient care services, caregivers are turning to clinical pathways to more effectively manage perioperative patients. Often, such pathways are generic (covering, for instance, all orthopedic or all vascular procedures). Such paths are especially helpful for organizations wishing to use the path for documentation purposes. In developing perioperative pathways, identify the specific patient care outcomes to be achieved; review patient records, nursing practice standards, and other materials to identify the common elements of care; and decide upon a process for reporting variances.
Care paths and patient pathways are collaborative interdisciplinary tools developed to provide quality care. One goal in progressive renal insufficiency (PRI) care is to provide patients and family members with relevant and timely information to help them cope with medical therapy and lifestyle changes required to slow the progression of renal insufficiency. At Halton Healthcare Services, clinical and patient pathways have been widely used with success. Recognizing the potential benefits of a patient pathway for the PRI population, our interdisciplinary team developed a pathway that outlines the journey to renal replacement therapy. The pathway provides the patient with some insight into the future, as their disease process continues to have impact on their life. Reviewed by a patient within our PRI program during the development process, we have tailored this pathway to meet the needs of this unique population. We predict this patient pathway will have positive impact on the patient's understanding of the role of the PRI clinic and the partnership between the team members, the patient, and the family.
We evaluated the usefulness of our original all-in-one clinical pathway for transurethral resection of the prostate (TUR-P) on 86 consecutive patients. There were 27 consecutive patients treated before introduction of the clinical pathway (group 1). Twenty-nine consecutive patients were treated just after the introduction of the clinical pathway (group 2) and 30 consecutive patients were treated one year after the introduction of the clinical pathway (group 3). Our pathway includes all items such as vital sign charts and events charts. Although the hospitalization ranged from 5 days to 12 days after introduction of the clinical pathway, the average length of hospital stay was shortened by 2.6 days in group 3. Although the duration of the postoperative indwelling urethral catheter ranged from 2 days to 7 days in the groups 2 and 3, the average duration was approximately 4 days in group 3. Postoperative complications did not differ among the three groups. The medical insurance claims decreased with the introduction of the clinical pathway. Our all-in-one clinical pathway is considered to be a good tool for not only reduction of health care costs but also giving higher quality and better service to patients.