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At least 1,729 records · Page 96Linked to original sources
PubMed1999

Clinical pathways in hip and knee arthroplasty: a prospective randomised controlled study.

OBJECTIVE: To ascertain the effectiveness of clinical pathways for improving patient outcomes and decreasing lengths of stay after hip and knee arthroplasty. DESIGN AND SETTING: Twelve-month randomised prospective trial comparing patients treated through a clinical pathway with those treated by an established standard of care at a single tertiary referral university hospital. PARTICIPANTS: 163 patients (56 men and 107 women; mean age, 66 years) undergoing primary hip or knee arthroplasty, and randomly allocated to the clinical pathway (92 patients) and the control group (71 patients). MAIN OUTCOME MEASURES: Time to sitting out of bed and walking; rates of complications and readmissions; match to planned discharge destination; and length of hospital stay. RESULTS: Clinical pathway patients had a shorter mean length of stay (P = 0.011), earlier ambulation (P = 0.001), a lower readmission rate (P = 0.06) and closer matching of discharge destination. There were beneficial effects of attending patient seminars and preadmission clinics for both pathway and control patients. CONCLUSION: Clinical pathway is an effective method of improving patient outcomes and decreasing length of stay following hip and knee arthroplasty.

Activities of Daily Living↗
PubMed2003

Integrated care pathway: the prevention and management of pressure ulcers.

The introduction of this pathway for the prevention and management of pressure ulcers was influenced by the development of the pathway for the management of a patient with a fractured neck of femur. Systematic documentation of preventative measures for patients with a fractured neck of femur helped reduce the incidence of pressure ulcers in this high-risk group. The original draft was informed by evidence-based clinical practice guidelines. This draft of the pathway was piloted, reviewed and changed in line with current evidence and comments from users. It was invaluable to pilot the pathway and review as necessary in order to make this a true workable document that would enable continuity of care, help prevent hospital-acquired pressure ulcers and be an effective teaching aid. A trust-wide retrospective audit of documentation for the prevention and management of pressure ulcers has been conducted, which found that the pathway facilitated a more concise approach to inform care than standard documentation. A further audit has been undertaken in the care of the elderly directorate which has demonstrated various ways in which the pathway had been completed. Challenges remain for the effective use of this documentation. Further education needs to be completed in order to promote multiprofessional use of the pathway. The pathway is now being integrated into others, which will increase awareness and involvement of other professional groups in this important aspect of patient care. Ongoing audit will take place to assess the impact upon patient outcomes.

Activities of Daily Living↗
PubMedDate not supplied

A clinical pathway for endoscopy.

The purpose of this article is to describe the development and use of a clinical pathway in an endoscopy setting. The goal was to incorporate all of the established practices of each discipline--nursing, medicine, admissions, laboratory, radiology, and others--without changing their practice models. The clinical pathway is the framework for all the activities in the management and practice of the unit, including the nursing standard of care, nursing competency-based practice, hospital policy and procedures, quality improvement, risk management, and physician preference.

Critical Pathways↗
PubMedDate not supplied

Constipation services for children: the role of health visitor teams.

Constipation among children is a prevalent condition, yet poorly understood. There is little empirical evidence for 'best possible' configurations of services. This article presents a survey of Walsall health visitor team members (HVTMs) which aimed to identify the types of advice and care provided to young children with constipation, pathways to care and ideas for service improvement. Most HVTM consultations were parent-initiated. Few GPs referred children to HVTMs. HVTMs most commonly provided advice about fluids and diet -- only one prescribed medication. HVTMs identified the need for early intervention, consistent information for parents and a clear pathway for all health professionals to follow. Currently, a team from the local primary and hospital NHS trusts is developing an integrated care pathway for paediatric constipation. Success of such pathways depends on their adoption by GPs and hospital-based health professionals, and on evidence of efficacy arising from their evaluation.

Aftercare↗
PubMed1998

Nursing case management in the NICU: enhanced coordination for discharge planning.

A primary goal of health care today is finding alternative ways to provide high-quality, cost-effective care. A model of care that addresses these issues is nursing case management. This article describes the development and implementation of nursing case management in a Level III regional center with the primary goal of enhancing coordination for discharge planning. The model involves development of clinical pathways and utilization of nurse practitioners as case managers. Decreased length of stay, charge per case, and readmission rates are demonstrated following implementation of this program.

Case Management↗
PubMed1996

Using severity-adjusted data to impact clinical pathways.

Feeling the weight of managed care, doctors and nurses at a Midwestern health system have joined forces to reduce costs and average lengths of stay (LOS) in a key practice area--orthopedics. The result has been a 40 percent decrease in average length of stay over a three-year period.

Critical Pathways↗
PubMed2003

Metabolic partitioning of endogenous fatty acid in adipocytes.

OBJECTIVE: To develop an accurate new method to measure the partitioning of adipocyte endogenous fatty acids among different metabolic pathways, a critical step toward understanding the regulatory mechanism by which fat disposition is modulated. RESEARCH METHODS AND PROCEDURES: Isolated primary rat adipocytes were pre-incubated with isotope-labeled fatty acids. This allows determination of the specific activity of labeled fatty acids in the endogenous lipid pool. After the removal of exogenous fatty acids, the disposition of endogenous fatty acids into the three major metabolic pathways, namely, oxidation, re-esterification, and release into the medium, was measured independently. This was compared with the total lipolytic release of endogenous fatty acids, as measured by glycerol release. Adipocytes from normal fed and fasted animals were used to determine the effects of physiological variations on the metabolic fate of endogenous fatty acids. RESULTS: In normal fed animals, 0.2% of endogenous fatty acids were oxidized, 50.1% were released, and 49.7% were re-esterified. Fasting doubled the partitioning of fatty acids toward oxidation (p < 0.05) in association with increased lipolysis (1.4-fold increase) (p < 0.05). This effect was completely abolished by the addition of insulin to the cells (61% reduction) (p < 0.05). DISCUSSION: The endogenous fatty acids in adipocytes are actively oxidized. This process can be regulated by altered physiological conditions or by insulin. Over time, it is possible that a small shift of fatty acids toward oxidation could have a significant impact on body fuel economy. This hypothesis needs to be tested.

Adipocytes↗
PubMed1993

Role of proteasomes in antigen presentation.

Recent studies have demonstrated that the proteasome, in addition to functioning in the complete degradation of cell proteins, is the source of most antigenic peptides presented to the immune system on major histocompatibility complex (MHC)-class I molecules. In this process, intracellular and viral proteins are degraded in the cytosol to 8- to 9-amino acid fragments, which are then transported into the endoplasmic reticulum, where they become associated with MHC-class I molecules and are thus delivered to the cell surface. A variety of evidence has shown that the proteasome and ATP-ubiquitin-dependent pathway are critical in this process: (1) In cells, selective inhibitors of proteasome function inhibit the bulk of protein degradation and thus prevent the generation of peptides necessary for class I presentation and the appearance of MHC on the cell surface. (2) Mutations that block ubiquitin conjugation prevent the generation of an antigenic peptide. (3) Modifications that lead to rapid degradation of a protein by the ubiquitin pathway enhance antigen presentation. (4) gamma-Interferon (gamma-IFN) induces new proteasome subunits, LMP2 and LMP7, encoded in the MHC region that are incorporated in place of constitutive proteasome subunits. Their incorporation does not affect rates of protein breakdown but causes changes in peptidase activities, i.e. they increase rates of cleavage after basic and hydrophobic residues and decrease cleavage after acidic residues. Transfections of cells with LMP2 or LMP7 cause similar changes in these peptidase activities as are caused by gamma-IFN. These modifications in peptidase activities should enhance the production of those types of peptides which are preferentially transported into endoplasmic reticulum and selectively bound to MHC-class I molecules.

Adenosine Triphosphate↗
PubMed2001

I kappa B kinase is critical for TNF-alpha-induced VCAM1 gene expression in renal tubular epithelial cells.

The expression of VCAM1 is up-regulated in renal proximal tubular epithelial cells (TEC) in a variety of inflammatory renal diseases, a prominent example of which is acute renal allograft rejection. VCAM1 may play an important role in these diseases because it binds to the integrins very late Ag-4 and alpha(4)beta(7) on lymphocytes and monocytes, thereby providing a potential mechanism to recruit these leukocytes to sites of inflammation. The molecular mechanisms underlying VCAM1 regulation in renal TEC are essentially unknown. We now report that VCAM1 mRNA is dramatically up-regulated in C1, a cell line derived from renal TEC, on exposure to TNF-alpha. Two NF-kappaB binding sites in the VCAM1 promoter are critical for the TNF-alpha-induced VCAM1 transcriptional up-regulation, and both sites bind to p65-p50 NF-kappaB complexes. TNF-alpha induces activation of inhibitor of NF-kappaB (IkappaB) kinase-beta (IKK-beta), a protein kinase that phosphorylates the NF-kappaB inhibitor IkappaB, and thereby targets the latter for degradation via the ubiquitin-proteasome pathway. Moreover, dominant negative versions of IKK inhibit TNF-alpha activation of a VCAM1 promoter reporter. We conclude that the IKK/NF-kappaB pathway is critical in the TNF-alpha-induced up-regulation of VCAM1 mRNA in renal TEC.

Animals↗
PubMed2000

Bid, a critical mediator for apoptosis induced by the activation of Fas/TNF-R1 death receptors in hepatocytes.

The Bcl-2 family proteins consist of both antiapoptosis and pro-apoptosis members that regulate apoptosis typically at the mitochondrial level, mainly by controlling the release of cytochrome c and other mitochondrial apoptotic events. However, death signals mediated by Fas/TNF-R1 receptors can usually activate caspases directly, bypassing the need for mitochondria and escaping the regulation by Bcl-2 family proteins. Bid is a novel pro-apoptosis Bcl-2 family protein that is activated by Caspase 8 in response to Fas/TNF-R1 death receptor activation. Activated Bid is translocated to mitochondria and induces cytochrome c release, which in turn activates the downstream caspases. This Bid-mediated pathway is critical in hepatocyte apoptosis induced by Fas/TNF-R1 engagement, where direct activation of cytosolic caspase cascade seems inefficient. The dependence on Bid, and thus on the mitochondrial cytochrome c release, of hepatocyte apoptosis induced by the death receptors also renders it sensitive to the inhibitory regulation by the anti-apoptosis members of the Bcl-2 family proteins, such as Bcl-2 and Bcl-xL. Moreover, the revealing of this death pathway in hepatocytes is important to the understanding of the pathogenesis of a number of hepatic diseases such as hepatitis or endotoxemia-related hepatic failure.

Antigens, CD↗
PubMed2006

Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia: a randomized controlled trial.

CONTEXT: Nursing home residents with pneumonia are frequently hospitalized. Such transfers may be associated with multiple hazards of hospitalization as well as economic costs. OBJECTIVE: To assess whether using a clinical pathway for on-site treatment of pneumonia and other lower respiratory tract infections in nursing homes could reduce hospital admissions, related complications, and costs. DESIGN, SETTING, AND PARTICIPANTS: A cluster randomized controlled trial of 680 residents aged 65 years or older in 22 nursing homes in Hamilton, Ontario, Canada. Nursing homes began enrollment between January 2, 2001, and April 18, 2002, with the last resident follow-up occurring July 4, 2005. Residents were eligible if they met a standardized definition of lower respiratory tract infection. INTERVENTIONS: Treatment in nursing homes according to a clinical pathway, which included use of oral antimicrobials, portable chest radiographs, oxygen saturation monitoring, rehydration, and close monitoring by a research nurse, or usual care. MAIN OUTCOME MEASURES: Hospital admissions, length of hospital stay, mortality, health-related quality of life, functional status, and cost. RESULTS: Thirty-four (10%) of 327 residents in the clinical pathway group were hospitalized compared with 76 (22%) of 353 residents in the usual care group. Adjusting for clustering of residents in nursing homes, the weighted mean reduction in hospitalizations was 12% (95% confidence interval [CI], 5%-18%; P = .001). The mean number of hospital days per resident was 0.79 in the clinical pathway group vs 1.74 in the usual care group, with a weighted mean difference of 0.95 days per resident (95% CI, 0.34-1.55 days; P = .004). The mortality rate was 8% (24 deaths) in the clinical pathway group vs 9% (32 deaths) in the usual care group, with a weighted mean difference of 2.9% (95% CI, -2.0% to 7.9%; P = .23). There were no significant differences between the groups in health-related quality of life or functional status. The clinical pathway resulted in an overall cost savings of US 1016 dollars per resident (95% CI, 207 dollars-1824 dollars) treated. CONCLUSION: Treating residents of nursing homes with pneumonia and other lower respiratory tract infections with a clinical pathway can result in comparable clinical outcomes, while reducing hospitalizations and health care costs. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00157612.

Aged↗
PubMed2003

Reduced medicolegal risk by compliance with obstetric clinical pathways: a case--control study.

OBJECTIVE: To estimate whether guideline compliance affected medicolegal risk in obstetrics and whether malpractice claims data can provide useful information on guideline noncompliance by focusing on the claims experience of a large health system delivering approximately 12000 infants annually. METHODS: We retrospectively identified 290 delivery-related (diagnosis-related groups 370-374) malpractice claims and 262 control deliveries at the health system during the period from 1988 to 1998. Clinical pathways for vaginal and cesarean delivery implemented in 1998 were used as a "standard of care." We compared rates of noncompliance with the pathways in the claims and control groups, calculated an odds ratio for increased risk of being sued given departure from the guideline standards, and calculated the elevated risk of litigation introduced by noncompliance. We also compared the frequencies of different types of departures across claims and control groups. RESULTS: Claims closely resembled controls on several descriptive measures (mother's age, location of delivery, type of delivery, and complication rates), but noncompliance with the clinical pathway was significantly more common among claims than controls (43.2% versus 11.7%, P <.001; odds ratio = 5.76, 95% confidence interval 3.59, 9.2). In 81 (79.4%) of the claims involving noncompliance with the pathway, the main allegation in the claim related directly to the departure from the pathway. The excess malpractice risk attributable to noncompliance explained approximately one third (104 of 290) of the claims filed (attributable risk = 82.6%). There were no significant differences in the types of deviation from the guidelines across claims and control groups. CONCLUSION: In addition to reducing clinical variation and improving clinical quality of care, adherence to clinical pathways might protect clinicians and institutions against malpractice litigation. Malpractice data might also be a useful resource in understanding breakdowns in processes of care.

Adult↗
PubMed2004

The effectiveness of implementing a care pathway for femoral neck fracture in older people: a prospective controlled before and after study.

OBJECTIVES: To investigate whether a care pathway for older hip fracture patients can reduce length of stay while maintaining the quality of clinical care. DESIGN: Prospective study of patients admitted 12 months before and after implementation of a care pathway for the management of femoral neck fracture. Audit data for corresponding time periods from nearby orthopaedic units was used to control for secular trends. SETTING: Teaching hospital. SUBJECTS: Patients aged 65 years and over with a femoral neck fracture. EXCLUSION CRITERIA: multiple fractures, fractures due to malignancy, re-fracture, total hip replacement, previously entered into the study, operation performed elsewhere. Three-hundred and ninety-five (99%) and 369 (97%) case records were available for full analysis. MAIN OUTCOME MEASURES: primary outcome: length of stay on the orthopaedic unit. SECONDARY OUTCOMES: ambulation at discharge, discharge destination, in-hospital complications, 30 day mortality, readmission within 30 days of discharge, post-operative days the patient first sat out of bed and walked. RESULTS: Mean length of stay increased by 6.5 days (95% confidence interval 3.5-9.5 days, P < 0.0005) in the second period with a significant improvement in ambulation on discharge (odds ratio 1.6, 95% confidence interval 1.0-2.6, P = 0.033) and a trend towards reduction in admission to long term care (odds ratio 0.6, 95% confidence interval 0.3-1.0, P = 0.058). CONCLUSIONS: This care pathway was associated with longer hospital stay and improved clinical outcomes. Care pathways for hip fracture patients can be a useful tool for raising care standards but may require additional resources.

Aged↗
PubMedDate not supplied

A clinical pathway for pediatric gastroenteritis.

Gastroenteritis is one of the most common reasons for hospitalization in the United States for children under the age of 5 years. Second only to respiratory problems, the cost of providing care for these children is estimated to exceed $2 billion dollars annually ( Burkhart, 1999; Prescilla, 2002). This article reviews the causes of gastroenteritis as well as the 1996 American Academy of Pediatrics Guidelines for treatment of gastroenteritis. These guidelines and more recently published literature were used to develop a clinical pathway to improve the care of pediatric patients admitted to the hospital with gastroenteritis. The article discusses the importance of clinical pathways and the process of implementation of a pathway for pediatric gastroenteritis. Additionally, the article provides a parent teaching tool to address recurrent questions parents have related to home management of a child with gastroenteritis. Useful web sites for resource information related to gastroenteritis are provided as well.

Child, Preschool↗
PubMedDate not supplied

Developing a hospital policy for clinical pathways.

Clinical pathways are used for planning, coordinating and facilitating the continuum of patient care from before admission to after discharge. They rapidly are changing the provision of healthcare services through improved patient care and cost containment, but they also have raised questions about possible legal ramifications. If sound policies and procedures for clinical pathways are developed and consistently adhered to by healthcare facilities, the potential for liability may be minimized while patient care is improved. This article describes a multidisciplinary task force's work to develop such policies and procedures.

Confidentiality↗
PubMedDate not supplied

An evidence-based clinical pathway for bronchiolitis safely reduces antibiotic overuse.

The overuse of antibiotics in the management of bronchiolitis is widely known, yet physician practice has been slow to change. We report here on the success of a clinical pathway in reducing antibiotic overuse in the inpatient management of bronchiolitis. The charts of 181 children admitted for bronchiolitis were reviewed to determine whether antibiotic use was reduced in patients managed using a clinical pathway compared with a matched group of patients managed without use of the pathway (non-pathway group). Only 9% of the pathway patients received antibiotics compared with 27% of the nonpathway group. No negative effects were seen on other quality measures including unplanned return for care. Furthermore, for patients managed using the clinical pathway, cost and length of stay were significantly reduced. Overall, the study suggests that implementation of a clinical pathway may be an effective means to change physician practice and reduce the unnecessary use of antibiotics, while maintaining or improving other aspects of quality of care.

Anti-Bacterial Agents↗
PubMed1997

Integration of behavioral medicine into general practice = better outcomes, lower costs.

Health care organizations save by looking beyond the basics of prescribing pills and taking to the operating table. Experts in behavioral medicine have developed six pathways to identify high-cost patients who may benefit from relaxation techniques and psychiatric counseling more than they can from biomedical care. Learn how to cut costs with formal behavioral medicine programs that are being instituted around the country.

Behavioral Medicine↗
PubMed2003

Establishing an end-of-life program in an academic acute care hospital.

The primary goal of end-of-life (EOL) care is to relieve suffering through measures that improve comfort and address the psychological, social, and spiritual needs of the dying. This article discusses the components of a pilot project that focused on palliative EOL care at an academic acute care hospital. An interdisciplinary team of nurses, social workers, chaplains, patient care coordinators, and advanced practice nurses established a common vision for the care of patients who were "in the dying process," or were expected to die during their hospitalizations. A nurse-social worker "Care-Pair Team" completed a consistent interdisciplinary EOL care needs assessment when treatment goals became strictly palliative. Interventions were driven by a clinical pathway and a pre-printed physician's order set that continually clarified the goals of treatment. Key elements of the program included leadership support, advance directives, education, communication, family involvement, symptom management, professional collaboration, and outcomes measurement.

Critical Pathways↗