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PubMed2006

Developing the Liverpool Care Pathway for the dying child.

In most western societies the death of a child is a rare occurrence. When it does occur, it typically takes place after a period of intensive and often prolonged treatment. In light of the relative infrequency of these events in clinical practice, ensuring that all dying children and their families receive consistent and appropriate care remains a challenge. A retrospective audit of documentation of care for dying children in two paediatric units in the north-west of England illustrated that the care provided was not always documented consistently. This paper highlights work currently underway to develop an integrated care pathway for the care of the dying child based on the Liverpool Care Pathway (LCP). The aim of this work is to facilitate the delivery and recording of optimum care for all dying children and their families.

Adolescent↗
PubMed1998

Does age limit the effectiveness of clinical pathways after coronary artery bypass graft surgery?

BACKGROUND: Clinical pathways have been shown to be effective in reducing the length of hospital stay after isolated CABG. Few studies, however, have focused specifically on the outcomes of the pathways in regard to the elderly population. METHODS AND RESULTS: We reviewed our experience with 445 consecutive patients (299 < 70 years old [mean age, 58.2 +/- 0.5 years] and 146 > or = 70 years old [mean age, 75.6 +/- 0.3 years]) who underwent isolated CABG with the expectation of progressing through the same 5-day postoperative pathway. Preoperatively, the elderly had a smaller body surface area (1.87 +/- 0.02 versus 2.00 +/- 0.01; P < 0.001) and a higher incidence of female gender (45.9% versus 26.8%; P = 0.001), cerebrovascular disease (13.7% versus 7.0%; P = 0.022), congestive heart failure (22.6% versus 13.4%; P = 0.013), and 3-vessel coronary artery disease (76.7% versus 65.9%; P = 0.024). Postoperatively, the elderly had a higher incidence of red blood cell transfusion (28.8% versus 9.0%; P = 0.001), atrial fibrillation (37.6% versus 11.7%; P = 0.001), and overall rate of complications (46.6% versus 23.4%; P = 0.001). Mortality rate and length of stay were 5.5% and 7.9 +/- 0.4 days for the elderly versus 1.0% and 6.4 +/- 0.4 days for those < 70 years old (P = 0.004 and P = 0.008), respectively. Of those > or = 70 years old, 34% were discharged in < or = 5 days, 64% in < or = 7 days, and 82% in < or = 10 days versus 64%, 85%, and 93%, respectively, for younger patients (P = 0.001 for all). Multivariate analysis of preoperative variables identified age (P < 0.001), female gender (P < 0.001), hypertension (P = 0.017), chronic obstructive pulmonary disease (P = 0.002), preoperative intra-aortic balloon pumping (P = 0.002), and body surface area (P = 0.003) as significantly related to length of stay. However, when the postoperative variables found to be different by univariate analysis are added to the model, age is only marginally significant (P = 0.079), and red blood cell transfusion and atrial fibrillation are the strongest predictors of increased length of stay, along with intra-aortic balloon pumping and pneumonia (P < 0.001 for all). CONCLUSIONS: These data suggest that extraordinary modifications of clinical pathways are not needed for success with elderly patients. The increased length of stay is largely attributable to the increased incidence of atrial fibrillation.

Age Distribution↗
PubMed1998

An evidenced-based clinical pathway for acute appendicitis decreases hospital duration and cost.

BACKGROUND/PURPOSE: In the pediatric population, appendicitis remains the most common surgical emergency encountered. The purpose of this study was to determine the impact of an evidence-based clinical pathway for acute appendicitis on patient care as well as hospital and home care costs at the authors' pediatric institution. METHODS: A prospective evaluation was conducted of an appendicitis clinical pathway (June 1996 through November 1996) compared with historical control patients (June 1994 through November 1994) not cared for by the pathway. RESULTS: Data (average +/- SD) for 120 pathway (P) patients were compared with 122 control (C) patients. Age (11.5 +/- 3.6 years for C v 11.2 +/- 3.9 years for P), rates of negative appendectomy (12.3% for C v 9.2% for P) and perforation (26.2% for C v 18.3% for P) were similar. Pathway patients with nonperforated appendicitis were more often discharged from the hospital within 24 hours (48% for C v 67% for P; P = .014) with lower hospital costs ($4,095 +/- $1,280 for C v $3,638 +/- $1,633 for P; P = .001). Pathway patients with perforated appendicitis had shorter hospitalization (185.2 +/- 59 hours for C v 113 +/- 44 hours for P; P = .0001) and lower hospital costs ($11,175 +/- $3,893 for C v $7,823 +/- $2,366 for P; P = .0001). CONCLUSION: An evidence-based appendicitis pathway decreased duration of hospitalization and cost without adversely affecting diagnosis or therapy. Clinical pathways for surgical diagnoses may prove useful as a means to minimize costs without compromising patient care.

Acute Disease↗
PubMedDate not supplied

[Impact of a clinical pathway for stroke patients].

OBJECTIVE: To assess the impact of the implementation of a clinical pathway for stroke patients. METHODS: We performed a controlled intervention study without random allocation that compared two non-concomitant cohorts of stroke patients corresponding to the periods immediately before (control group) and after (intervention group) the implementation of a clinical pathway. The main outcome measures were: a) quality of care indicators; b) improvements in functional capacity (Barthel score) and neurological function (Canadian scale); c) nosocomial complications; d) satisfaction, and e) mean length of hospital stay. RESULTS: One hundred and thirty-nine patients were recruited. Sixty-nine corresponded to the period before implementation of the pathway and 70 corresponded to the period after implementation. There were no significant differences between the two groups on admission. A 36.5% reduction in the time from admission to mobilization was observed. No significant differences were observed between the groups for the other quality of care indicators, or in improvements in functional and neurological capacity. Nosocomial complications occurred in 44.5% of patients in the control group compared with 28.6% in the intervention group (p = .039). No significant differences were observed in the overall satisfaction assessment, but patients in the intervention group showed greater satisfaction in the dimensions of "information" and "trust and professionalism". The mean length of hospital stay was reduced from 11 to 10 days. CONCLUSIONS: The implementation of the stroke clinical pathway contributed to reducing the length of hospital stay and the number of inpatient complications, as well as to improving some quality of care indicators.

Aged↗
PubMed1997

Carotid endarterectomy clinical pathway: a nursing perspective.

The changing demands of the health care environment require that more effective treatments be used to lower costs and decrease length of stay. Clinical pathways provide a detailed plan of care and are one method available to achieve these goals. The carotid endarterectomy pathway was selected as the first pathway developed because of the short length of stay and its history of few complications. The process of developing the pathway gave the multidisciplinary team a chance to rethink individual practices and rid themselves of old habits. The results showed a decreased length of stay, lower costs, and maintenance of high patient outcomes. The positive impact also required changes in teaching tools.

Critical Pathways↗
PubMed1999

Using a collaborative research utilization model to develop and test the effects of clinical pathways for pain management.

The article reports a study that tested a practical multidisciplinary approach to address the prevailing research-to-practice gap in pain management. By means of a collaborative research utilization model, academic scientists and students from two affiliating colleges of nursing were paired with clinicians from medicine, nursing, social work, pastoral care, and physical therapy to form three partnerships to develop and evaluate 14 pain management clinical pathways. Results showed that patients whose caregiver used the pathways had less pain across their hospital stay, less interference by pain in nearly all quality of life indicators, and greater satisfaction with caregiver responsiveness to their pain. Each of these improvements reversed after discharge, however.

Cooperative Behavior↗
PubMed1998

Improvement in resource utilization after development of a clinical pathway for patients with pressure ulcers.

Clinical pathways are interdisciplinary patient care plans intended to reduce variance and improve quality of care while lowering health care cost. This study was undertaken to determine whether the development of a clinical pathway for care of patients with pressure ulcers can indeed decrease health care costs while preserving quality of care. A clinical pathway for surgical reconstruction of pressure ulcers was developed by standardizing the current practices of our plastic surgeon group. The pathway provided direction in optimal scheduling of physician interventions along with nursing, physical and occupational therapies, and spinal cord rehabilitation interventions. It covered all potential elements of patient care, including laboratory, radiology, dietary services, intravenous fluids, and use of specialty beds. It defined patient outcomes and outlined discharge planning. Pathways were distributed throughout all services caring for patients with pressure ulcers. Patient charts and billing data were reviewed for the 16-month periods before and after initiation of the pathway. No other significant changes in treatment occurred during this time frame. Ninety-seven patient charts were examined (54 before pathway and 43 after pathway implementation). Parameters evaluated included length of stay and total charges (including bed use, medications, laboratory tests, and radiology). Patient readmission rate was also examined. A significant reduction in patient length of stay and total charges was achieved after implementation of the clinical pathway. Reduction was seen not only for patients treated with flaps by plastic surgery but also for patients with pressure ulcers who were not specifically targeted such as those from other services. The readmission rate decreased slightly, although not significantly, after the pathway inception. Total cost saving was almost $11,000 per patient (23 percent). In conclusion, implementation of a clinical pathway, because it standardizes care and reduces variations and duplication of care, can reduce health care cost without impairing quality of care in the treatment of decubitus ulcer patients.

Costs and Cost Analysis↗
PubMedDate not supplied

Integrating service excellence in a CHF clinical pathway pilot project.

The complex dynamics of the current healthcare environment require healthcare delivery systems to become cost effective and quality driven. Educated healthcare consumers expect superior service and timely responses to their needs. For one healthcare system, customer expectations were an integral part of designing, implementing, and measuring the service components of congestive heart failure pathway outcomes. Service excellence can influence overall clinical outcomes when measured by consumer awareness and patient satisfaction. The inclusion of service excellence as an intrinsic piece of the organizational strategic plan laid the groundwork for this integrated pilot project.

Critical Pathways↗
PubMed1997

Clinical pathways for the terminally ill.

Clinical pathways help providers to enhance documentation, standardize care, and improve patient outcomes. One agency developed a clinical pathway that offers terminally ill patients comprehensive, accessible, and coordinated care. It prompts each team member to recognize positive outcomes and to conduct ongoing goal setting with the patient and family.

Attitude of Health Personnel↗
PubMed1998

Total knee pathway weds acute care, rehab.

The cross-continuum pathway at St. David's Medical Center in Austin, TX, has allowed case managers to reduce length of stay by four days and cut rehab costs by $300 per day by stressing early mobilization of patients and an aggressive regimen of physical therapy (PT). Because patients are expected to undergo as much as six hours of PT per day, only about half of St. David's total knee population is appropriate for the pathway. These consist of healthy older adults with few medical complications who had been somewhat active prior to surgery. Based on the pathway, case managers helped create St. David's Progressive Orthopedic Program, which allows acute care and rehabilitation nurses to work more closely in screening patients and smoothing the transition from the hospital to the outpatient setting.

Arthroplasty, Replacement, Knee↗
PubMed2004

New tools capitalize on telehealth opportunities.

Introducing the 'telehealth pathway.' With the increasing amount of care management being conducted over the phone, it seems only logical that pathways would be developed to guide clinicians in this process. Find out how this new tool can help care managers reach more patients in a limited amount of time, and where developers believe it can have the biggest impact.

Attitude to Computers↗
PubMed2005

The use and modification of clinical pathways to achieve specific outcomes in bariatric surgery.

Clinical pathways are promoted for standardizing patient care and decreasing resource use without compromising outcome. Once established, we hypothesized that clinical pathways can then be used to modify patient care to achieve specific goals. Our aim was to evaluate a clinical pathway for the bariatric surgical patient that was initially designed to standardize care and later altered to modify the postoperative course. We retrospectively reviewed 150 consecutive patients undergoing open gastric bypass by a single surgeon. The first 50 patients were managed without a formal pathway, (group I). The next 50 were managed with a pathway that standardized care in order to reduce length of stay (LOS), (group II). For the final 50 patients, the pathway was modified to shorten nasogastric decompression time (group III). Patient information, blood loss (EBL), operative time, length of stay (LOS), nasogastric decompression, 30-day complication rates, and early readmissions were reviewed. The groups were similar with respect to gender, age, body mass index, American Society of Anesthesiologists (ASA) classification, and EBL. Operative time was significantly less in groups II and III compared to group I (82% and 68% vs. 38% <180 minutes, P < 0.05). LOS was shorter in groups II and III compared to group I (62% and 42% vs. 20% with a 4-day LOS, P < 0.05). Duration of nasogastric tube decompression was successfully decreased in group III when compared to groups I and II (76% vs. 14% and 6% 1 day or less, P < 0.05). Complication rates were significantly lower in group III as well (14% vs. 36% and 28%, P < 0.05). Standardizing patient care with a clinical pathway decreases LOS after bariatric surgery. An established clinical pathway can then be used to further modify patient care in order to achieve specific goals, such as shortened time of nasogastric decompression. This goal was accomplished without compromising patient outcome.

Adult↗
PubMed2005

Development of a clinical pathway for total knee arthroplasty and the effect on length of stay and in-hospital functional outcome.

The goal of reducing the length of a patient's hospital stay after orthopaedic surgery has recently gained much interest from surgeons and hospital administrators. The influence of hospital stay reduction on qualitative outcome is not always documented. The purpose of this study was to investigate this relationship in more detail. We report our experience with patients undergoing total knee arthroplasty. In 2000, an in-hospital clinical pathway for patients undergoing total knee arthroplasty was instituted at the University Hospitals Pellenberg, Belgium. We evaluated this pathway in 103 patients by using a pre-experimental, interrupted, time-series design. This pathway significantly decreased length of stay by 33% without negatively affecting functional outcomes during hospitalisation. In further research also the long-term effects have to be studied.

Aged↗
PubMedDate not supplied

Pathways in multidisciplinary oral health care as a tool to improve clinical performance.

PURPOSE: To investigate the optimization of multidisciplinary and interdisciplinary oral health care through the introduction of pathways. MATERIALS AND METHODS: A prospective randomized clinical trial was carried out in a tertiary referral academic institution. Ninety-one patients admitted for multidisciplinary oral health care from January 1, 2001, to March 31, 2003, were randomized to the test group (n = 50) or to the control group (n = 41). Pathways were implemented by means of the Medical Patient Management program, a computerized planning and coordination system specifically developed for a population with multidisciplinary oral rehabilitation needs. The efficiency of pathways in interdisciplinary oral health care was assessed. RESULTS: Statistically significant differences between test and control groups were found for variables regarding the process of care, such as "number of planned versus actual disciplines," "length of planned versus actual treatment," and "average length of a treatment session." For variables regarding patient satisfaction, significant differences between test and control groups were found for questions regarding patient involvement with the treatment and patient satisfaction with the outcome of multidisciplinary treatment. Regarding practitioner satisfaction, the results of the questionnaire indicate that implementation of pathways into everyday clinical practice is desired but remains difficult. CONCLUSION: The findings of this study show that the implementation of pathways in multidisciplinary oral health care improved some aspects of the process of care and increased patient satisfaction. The predictive capability of the Medical Patient Management program in managing oral health care has been demonstrated.

Attitude of Health Personnel↗
PubMed2006

What are the true advantages of a pediatric appendicitis clinical pathway?

Multiple protocols have been described for pediatric appendicitis, but few have been compared with off-protocol treatment. We performed such a comparison. Children treated for appendicitis by three pediatric surgeons over a 28-month period were studied. A protocol of primary wound closure without drains, standardized use of antibiotics, and patient discharge according to pre-determined clinical criteria was compared with individualized drain use, antibiotic selection, and discharge timing. Three hundred ninety-seven children were treated, 43 per cent on pathway (Group I) and 57 per cent off pathway (Group II). The two groups showed similar incidence of acute (45% vs 46%), complicated (50% vs 49%), and normal (5%) appendix. Among patients with simple appendicitis, Group I had less postoperative antibiotic use (16% vs 80% P < 0.001), shorter hospital stays (1.44 vs 1.89 days, P = 0.001), and decreased hospital charges (dollars 9,289 vs dollars 10,751, P = 0.001). Among patients with complicated appendicitis, Group I had less drain placement (4% vs 27%, P < 0.001), less use of discharge antibiotics (13% vs 39%, P < 0.001), and no readmission (0% vs 5%, P = 0.05). Infectious complications were similar between the two groups. A clinical pathway decreases the use of unnecessary antibiotics, hospital stay, and charges for simple appendicitis. It decreases the use of unnecessary drains, and eliminates readmissions after complicated appendicitis.

Abdominal Abscess↗
PubMed2005

The translocation mechanism of P-glycoprotein.

Multidrug transporters are involved in mediating the failure of chemotherapy in treating several serious diseases. The archetypal multidrug transporter P-glycoprotein (P-gp) confers resistance to a large number of chemically and functionally unrelated anti-cancer drugs by mediating efflux from cancer cells. The ability to efflux such a large number of drugs remains a biological enigma and the lack of mechanistic understanding of the translocation pathway used by P-gp prevents rational design of compounds to inhibit its function. The translocation pathway is critically dependent on ATP hydrolysis and drug interaction with P-gp is possible at one of a multitude of allosterically linked binding sites. However, aspects such as coupling stoichiometry, molecular properties of binding sites and the nature of conformational changes remain unresolved or the centre of considerable controversy. The present review attempts to utilise the available data to generate a detailed sequence of events in the translocation pathway for this dexterous protein.

ATP Binding Cassette Transporter, Subfamily B, Mem↗
PubMed1997

Tonsillectomy and adenoidectomy pathway plan of care for the pediatric patient in day surgery.

The care of children undergoing tonsillectomy and adenoidectomy (T&A) in the day surgery setting can be costly, due in a large part to the length of stay after surgery. A clinical pathway standardizes the length of stay and, therefore, directly controls costs associated with outpatient T&A. A T&A pathway plan of care was developed at one institution to (1) decrease the cost of the procedure, (2) improve parent/patient satisfaction, and (3) maintain or improve the quality of care.

Adenoidectomy↗