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PubMed2002

Do multidisciplinary integrated care pathways improve interprofessional collaboration?

This paper reports on the evaluation stage of an action research project on interprofessional collaboration in discharge planning. Findings from interviews with health care professionals working in the acute sector had revealed concerns about discharge planning and multidisciplinary teamwork. In the United Kingdom the National Health Service (NHS) Plan has reinforced the need for an integrated approach to health care. Effective health care integration requires effective communication, teamwork and the commitment to deliver integrated care. Integrated documentation is a key strategy for enhancing interprofessional collaboration and reducing the isolation of professionals, and has been successfully implemented in a range of health care settings. Presented with the concerns about the collaborative process in discharge planning, an action research strategy was chosen to bring about change in an orthopaedic ward in one London teaching hospital. This paper will evaluate the implementation of an integrated care pathway with fractured neck of femurs in one London teaching hospital. Care pathways facilitate the management of defined patient groups using interdisciplinary plans of care. The emphasis will be on understanding whether integrated care pathways enhance and develop interprofessional collaboration and enable effective information access and flow across the professions and the organization. The criteria for evaluation, forming the hypotheses of the study, were that interprofessional nonverbal and verbal communication would be enhanced and that interprofesisonal collaboration would increase. Methods of evaluation used were: (i) stakeholder interviews, (ii) interprofessional audit and (iii) analysis of the variances from the integrated care pathway. The evaluation revealed that although integrated care pathways led to improved outcomes for the health care trust there was little evidence to suggest that interprofessional relationships and communication were enhanced. Furthermore, key factors in discharge delays appeared to be organizational rather than professional.

Attitude of Health Personnel↗
PubMed2007

Success of clinical pathways for total joint arthroplasty in a community hospital.

Clinical pathways for total joint arthroplasty have been implemented successfully during the past decade. We report the results of pathway use for primary elective total hip and total knee arthroplasty in a community teaching hospital. We evaluated pathway efficacy using patient data forms and the hospital's financial database. Before instituting the pathway, the average length of stay was 4.41 days for patients having total hip arthroplasty and 3.92 days for patients having total knee arthroplasty. The average length of stay for patients having total hip arthroplasty decreased to 3.24 days and to 2.98 days for patients having total knee arthroplasty. Press Ganey Survey results showed high patient satisfaction rates before and after pathway initiation. Pathway implementation did not lead to increased complication rates or readmissions. Despite higher expected increases in the overall healthcare cost during the time of implementation (3 years), direct cost increases were limited to 3.48%. The key elements contributing to pathway success included preoperative patient education, standardized orders derived from evidence-based medicine, and a nurse practitioner who championed the pathway and ensured compliance. We recommend clinical pathways for patients having total joint arthroplasties to reduce length of stay, facilitate effective resource use, and preserve quality of care without compromising patient satisfaction or safety.

Aged↗
PubMed2003

Effectiveness of the clinical pathway in the management of congestive heart failure.

BACKGROUND: The prevalence of congestive heart failure (CHF) in the United States is approximately 4 million, with associated annual health care expenditures exceeding dollar 8 billion. Clinical pathways for CHF have been developed, but they have not been rigorously evaluated regarding efficacy and improvement in the quality of care. We sought to evaluate the effect of a CHF clinical pathway on hospital charges, length of stay, and use of angiotensin-converting enzyme (ACE) inhibitors in patients with CHF in a retrospective cohort study. METHODS: We studied 371 patients (age range, 44-92 yr) with discharge diagnoses of CHF in a 376-bed community hospital between July 1996 and December 1997. We conducted chart reviews to determine length of stay, hospital charges, and use of ACE inhibitors. RESULTS: Of the 371 patients, 174 were assigned to the clinical pathway and 197 were not. Baseline characteristics of the two groups were similar. The benchmark of less than 4 days' in-hospital stay was achieved in 65% of patients on the pathway and 42% who were not on the pathway (odds ratio, 2.6; 95% confidence interval, 1.67-4.05; P < 0.001). The median hospital charges were lower in the group on the clinical pathway (dollar 3,000 versus dollar 5,500, P < 0.001). In addition, 81% of the patients on the clinical pathway were administered ACE inhibitors, compared with 48% of equally eligible patients from the nonpathway group (odds ratio, 4.68; 95% confidence interval, 2.85-7.72; P < 0.001). CONCLUSION: The clinical pathway for CHF was associated with increased use of ACE inhibitors as well as reduced length of stay and hospital charges.

Adult↗
PubMed2005

Perceptions on individualized approaches to mental health care.

Ways of working on acute psychiatric units have come under intense scrutiny in order for service users to receive modern care and treatment. This has led to various ways not only to improve the therapeutic milieu on psychiatric wards, but also to develop standardized approaches to care. This paper reports on a study on the development of a care pathway for people diagnosed with schizophrenia, with the aim of standardizing the care process. Action research was used to develop the care pathway and views were collected, and observations made from a range of mental health professionals. Not all respondents were in agreement with a care pathway and this led to clinicians defending the individualized nature of psychiatric care. Implementation of a care pathway may help not only to rekindle the therapeutic purpose of psychiatric care, but also to build in the individualized approach to carrying out hospital care. Limitations of the study have also been briefly reported.

Acute Disease↗
PubMedDate not supplied

Identifying and managing problem scars.

A scar is a mark left in the skin by the healing of injured tissue. Outcome depends on the type of trauma causing the scar and how well it is repaired and managed initially. In most people, a scar heals to a fine line, but in others, the scar may grow in all directions, is elevated and remains hyperaemic. Excessive scar tissue is classified either as hypertrophic or keloid. Unfortunately, it is not always easy to predict those patients who will develop problematic scars that require referral to specialist scar management clinics. This article describes the development of a new universal scar risk assessment and management pathway. The pathway was designed specifically to assist practitioners in identifying patients who are at risk of developing problem scars after surgery and to clearly set out evidence-based standards of care that will assist and guide the management for those patients at risk.

Cicatrix↗
PubMed1997

Stem cell factor, the JAK-STAT pathway and signal transduction.

Recent work has demonstrated the importance of Janus family kinases (JAKs) and signal transducers and activators of transcription (STATs) in the stimulus-response coupling of receptors lacking intrinsic tyrosine kinase activity. In particular, the JAK-STAT pathway appears critical in signal transduction by interferon as well as numerous hematopoietic growth factors interacting with members of the hemapoietin receptor superfamily. Although ligands that interact with receptor tyrosine kinases (RTK), such as epidermal growth factor (EGF), platelet-derived growth factor (PDGF) and colony stimulating factor-1 (CSF-1), have been shown to induce increases in phosphorylation of both JAKs and STATs, little is known about activation of this pathway by stem cell factor (SCF). This review will summarize what is known about the JAK/STAT pathway in relation to SCF signal transduction.

Animals↗
PubMed2004

[Impact of a clinical pathway for the diabetic foot in a general hospital].

OBJECTIVE: The ulcers, infections and isquemia of the foot are the main causes of hospitalisation of the diabetic patient and, very frequently, they are reason for the amputation of the limb. The objective of this investigation consists of evaluating the results of a multidisciplinary clinical pathway designed by the set of specialists of different departments from our hospital, as well as of the associated personnel of infirmary, implied in the management of this pathology. PATIENTS AND METHODS: We have analysed the evolution of a series of clinical and socio-economic indicators comparing, in the patients admitted with diagnose of complicated diabetic foot, the previous period to the implantation of the clinical pathway years 1998, 1999 and 2000) with the later period to this implantation (years 2001 and 2002). It is evaluated in each group: the percentage of greater and smaller amputations, mortality, the average stay, the percentage of readmitances in 30 days, the percentage of arteriographies, the percentage of patients controlled by rehabilitation, and the economic cost of the individual processes, as well as the global cost. In the group including in the clinical pathway it was carried out, in addition, a satisfaction survey. The statistical comparison was made by means of the Chi square test. RESULTS: We did not find differences as far as the average stay, nor to intrahospitable mortality. If we found a clear increase in the percentage of arteriographies (of the 3.5% passage to 13%), and in the percentage of patients controlled by rehabilitation (of the 19.8% passage to the 84.3%). The rate of greater amputations of the patients not including in the clinical pathway change from 17.4% to 9.7% after the implantation of this route. The rate of readmitances to 30 days diminished from 9.3 to 6,5%. The global economic cost and the average cost by patient have been inferior after the implantation of the clinical route. The survey of satisfaction of this last group offered a global satisfaction of 95%. CONCLUSIONS: The results suggest that the approach to the diagnose and treatment on the complicated diabetic foot by means of this multidisciplinary clinical pathway improves the evolution of the hospitalised patient, diminishing the number of greater amputations, without extending the average stay and maintaining, or even diminishing, the global economic cost.

Amputation, Surgical↗
PubMedDate not supplied

Asthma clinical pathway: an interdisciplinary approach to implementation in the inpatient setting.

Asthma is a leading cause of admission to the pediatric inpatient setting. Despite advances in the treatment of this chronic condition, morbidity and mortality continue to increase. It is also a source of significant variation in clinical practice and redundancy of care elements across various disciplines involved in the management of patients with asthma. A clinical pathway was developed and implemented by a multidisciplinary team at The Children's Hospital of Philadelphia. The unique approach used to strategize implementation combined the expertise of registered nurses, respiratory therapists, medical staff, and case managers and was a significant factor in the pathway's ultimate success. The result was a more standardized and efficient approach to care. Outcome measurements revealed decreased length of stay with no increase in the re-admission rate and cost savings.

Algorithms↗
PubMed2002

Variance analysis applied to a stroke pathway: how this can improve efficiency of healthcare delivery.

INTRODUCTION: Stroke is a complicated disease that requires a multidisciplinary approach for its management. We postulated that variance analysis applied to a stroke pathway, by identifying major problem areas and encouraging timely corrective actions, would lead to more efficient healthcare delivery to hospitalised stroke patients. MATERIALS AND METHODS: Prospectively collected variance data from consecutive stroke patients discharged from a tertiary hospital in Singapore during a 3-month period in 2000 were used to identify the major variances causing increased length of stay. These were compared and contrasted to variance data collected during the same 3-month period in the subsequent year (2001), after the implementation of stroke pathway and the availability of monthly variance analysis reports. Patient characteristics and outcome measures were also compared between the two study periods. RESULTS: The four major variances that accounted for increased length of stay were, in descending order of the number of patients affected, awaiting bed availability in step-down facilities, delay in head computed tomographic scan performance, awaiting family's decision on discharge plan and incomplete application submitted to step-down facilities. After implementation of the stroke pathway with ongoing variance analysis, all four variances showed different extent of improvements. There were no significant differences in patient characteristics between the two study periods, whereas the average length of stay significantly diminished in the late study period with a trend for decreased in-hospital mortality, compared to the early study period. CONCLUSION: Variance analysis applied in the context of a stroke pathway was effective in identifying major variances causing increased length of stay. This allowed targeted intervention to improve efficiency of healthcare delivery to stroke patients.

Aged↗
PubMedDate not supplied

Implementation of a clinical pathway for laparoscopic colorectal surgery.

The purpose of this study was to assess through questionnaire the validity of our original clinical pathway for laparoscopic colorectal surgery. From 2001 to 2002, laparoscopic colorectal surgery was performed in 52 patients in our institution. All patients were out of bed within 3 days after the operation. The average postoperative hospital stay was 10.9 days. The implementation rate of the clinical pathway was 100%. As to the results of the questionnaire, 92.4% of the patients felt they could be discharged within 7 days after the operation, whereas >95% of the patients wanted to go home on a Sunday/holiday or the day before. All but 2 patients (96.2%) were satisfied with our therapy. In a clinical pathway for laparoscopic colorectomy, a high implementation rate and patients' satisfaction can be achieved by taking into account the patients' viewpoints; however, better patient education is necessary to shorten postoperative stay.

Colectomy↗
PubMed2006

The impact of an acute myocardial infarction guideline and pathway on racial outcomes at a university hospital.

OBJECTIVE: Historically, African Americans who present with acute myocardial infarction were less likely to survive or be revascularized compared to Whites in the United States. Variation in practice has been implicated as a cause. Some researchers have proposed that the explanation for this variation was that coronary artery disease (CAD) was less severe in African Americans than Whites. A university hospital compared the extent of CAD by race for its acute myocardial infarction (AMI) patients and determined the effect of implementing evidenced-based guidelines on racial differences in cardiovascular outcomes. METHODS: From 1991 to 1994, using the National Registry for Myocardial Infarction 1 and the hospital AMI database, 323 of the 521 consecutive patients were catheterized during their initial admission. The extent of CAD was defined as the frequency of CAD stenosis > or =70% seen in the major coronary arteries and/ or their major branches. Cardiac function was measured by left ventricular ejection fraction (LVEF). Short-term hospitalized outcomes were determined for death, treatment, and coronary revascularization. RESULTS: We assessed 82 (25.4%) African Americans and 241 (74.6%) Whites. No significant difference in the frequency of stenosis > or =70% or clinical outcomes existed between races. However, African Americans had a lower LVEF of 49.13% compared to 54.98% for Whites (P=.04). African Americans were 2.54 times more likely to have LVEF <45% (P=0.024). We saw no racial difference in death, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, or thrombolytic therapy. CONCLUSION: In high-risk AMI patients, this study found no difference in the burden of CAD by race. However, for African Americans, left ventricular function was more depressed. The use of an AMI management guideline and pathway-driven protocol resulted in no significant racial difference in cardiac interventions or clinical outcomes. A guideline or protocol-driven approach to the management of AMI may significantly reduce the observed racial

Black or African American↗
PubMed2025

Genetic insight into lung neuroendocrine tumors: Notch and Wnt signaling pathways as potential targets.

BACKGROUND: The molecular landscape of lung neuroendocrine neoplasms is still poorly characterized, making it difficult to develop a molecular classification and personalized therapeutic approaches. Significant clinical heterogeneity of these malignancies has been highlighted among poorly differentiated histotypes and within the subgroup of well-differentiated neuroendocrine tumors (NET). Currently, the main prognostic factors of lung NET include stage, histotype, grade, peripheral location, and demographic parameters. To gain deeper insights into the genomic underpinnings of lung NETs, we conducted a pilot investigation to uncover potential genetic mutations and copy number variations (CNVs) implicated in their pathogenesis. METHODS: Formalin-fixed, paraffin-embedded intraoperative tumor biopsies and matched peripheral blood mononuclear cell samples were collected from six consecutive patients with lung NETs. The whole exome sequencing (WES) was performed to profile germline and somatic mutations, identify novel genetic alterations, and detect CNVs. Clinical and pathological data were systematically documented at diagnosis and during follow-up. RESULTS: The WES analysis identified a subset of mutations shared between germline and somatic; some were of particular clinical interest as they were associated with tumor proliferation and potential therapeutic targets such as the genes KDM5C, ATR, COL7A1, NOTCH4, PTPRS, SMO, SPEN, SPTA1, TAF1. These mutations were predominantly linked to chromatin remodeling and were involved in critical oncogenic pathways such as Notch and Wnt signaling. CONCLUSIONS: This pilot study highlights the potential role of NGS analysis on solid biopsy in the assessment of the mutational profile of lung NET. A comparison of germline and somatic mutations is critical to identifying putative tumor driver mutations. In perspective, the enrichment of a subpopulation of cancer cells in the blood, with one or more specific mutations, is information of enormous clinical relevance, either for prognosis or therapeutic decisions. Translational studies on large prospective series are required to establish the role of liquid biopsy in lung NET.

Humans↗
PubMed1997

Pathways: improving outcomes, not just 'cookbook medicine'.

A Kaiser Permanente medical director cites four benefits to be derived from using clinical guidelines: better outcomes, faster patient recovery, reduced costs, and increased physician accountability. And, he notes, physicians are free to deviate from the guidelines--so long as they can justify their actions.

California↗
PubMed2004

Regulation of Hedgehog signaling: a complex story.

The Hedgehog (Hh) signal transduction pathway plays critical instructional roles during development. Activating mutations in human Hh signaling components predispose to a variety of tumor types, and have been observed in sporadic tumors occurring in a wide range of organs. Multiple insights into the regulation of Hh signaling have been achieved through studies using Drosophila melanogaster as a model organism. In Drosophila, regulation of the transcription factor Cubitus interruptus (Ci) is the ultimate target of the Hh pathway. Ci is regulated through communication of the membrane proteins Patched (Ptc) and Smoothened (Smo) to the intracellular Hedgehog Signaling Complex (HSC) in response to a graded concentration of Hh ligand. The HSC consists of the Kinesin Related Protein, Costal2 (Cos2), the serine-threonine protein kinase. Fused (Fu) and Ci. In the absence of Hh stimulation, the HSC is involved in processing of Ci to a truncated repressor protein. In response to Hh binding to Ptc, processing of Ci is blocked to allow for accumulation of full-length Ci activator protein(s). Differential concentrations of Hh ligand stimulate production of Ci transcriptional activators of varying strength, which facilitate activation of distinct subsets of target genes. The mechanism(s) by which Ptc and Smo communicate with the HSC in response to differential ligand concentrations to regulate Ci function are not yet fully elucidated. Here, we review what is known about regulation of individual Hh signaling components, concentrating on the mechanisms by which the Hh signal is propagated through Smo to the HSC.

Animals↗
PubMed2002

Design and impact of intraoperative pathways for head and neck resection and reconstruction.

OBJECTIVES: To describe the design and impact of 3 intraoperative pathways for the treatment of head and neck cancers; to detail the pathways schematically to illustrate projected intraoperative flow and teamwork; and to analyze impact on procedure and case lengths in each pathway and in comparison with historical prepathway average times. SETTING: Tertiary-level academic health system main operating room. PATIENTS: Twenty-one patients undergoing transcervical (TC) resection (n = 11), transmandibular (TM) resection (n = 8), or laryngopharyngectomy (LP) (n = 2) with radial forearm free-flap reconstruction for ablative or reconstructive reasons were pathway eligible. A convenience sample of 16 patients undergoing TC resection, 7 undergoing TM resection, and 7 undergoing LP prepathway is used for comparison. INTERVENTION: Our academic medical center uses 3 intraoperative clinical pathways to manage resource use and streamline care for patients. These 3 pathways were designed schematically by an interdisciplinary team. The pathways plan progression of the case by timed actions for surgical, anesthesia, and nursing teams. MAIN OUTCOME MEASURES: Procedure and case lengths. RESULTS: The TC pathway procedure and case length averaged 10.48 and 12.33 hours, respectively; TM pathway procedure and case lengths, 11.19 and 13.32 hours, respectively; and LP pathway procedure and case lengths, 12.42 and 13.83 hours, respectively. Aggregate averages were 10.93 hours and 12.85 hours for procedure and case length, respectively. The average pathway case lengths of 12.33, 13.32, and 13.83 hours compare favorably with our target times of 13, 14, and 15 hours, respectively. Environmental management, work flow, and team satisfaction anecdotally increased postpathway. CONCLUSIONS: Intraoperative pathways afford enhanced time and action efficiency to streamline care of patients undergoing head and neck procedures. Pathway implementation produced time savings. Our results suggest that implementation of such pathways will benefit similar academic medical centers seeking to improve intraoperative resource use to improve performance in the care of patients undergoing head and neck procedures.

Cervical Vertebrae↗
PubMed2006

[Clinical pathways: experiences, expectations, and perspectives].

Due to economic necessities, existing reserves in clinical practice have to be used efficiently. The presentation of medical activity and systematic illustration of medical decisions in the form of clinical pathways constitute important tools to ensure the quality of patient care under fiscal pressure caused by the DRG system. To successfully establish clinical pathways, the architecture of the standard operating procedures developed specifically for a hospital must adequately reflect medical concerns and patient-related needs. The concept of necessity for the good of the patient applies in this instance rather than the principle of the complete depiction of all medical processes. Organizing the implementation into clinical practice should be assured and monitored. The standard operating procedures should be regularly adapted to suit medical developments. Success with the procedure should be reported and deviations from predetermined targets should be documented. A clinical pathway does not represent an administrative end in itself but rather a part of a higher control system that helps to improve the utilisation of the hospital's resources in terms of reliability and quality of patient care.

Communication↗
PubMed2006

Patient perception of a clinical pathway for laparoscopic foregut surgery.

Clinical pathways have been implemented for a number of surgical procedures, yet few data are available that explore the patients' perception of these changes in clinical practice. A clinical pathway was developed for laparoscopic fundoplication, Heller myotomy, and paraesophageal hernia repair. Data collected from a cohort of patients undergoing surgery with the pathway over a 12-month period was compared with a group of patients operated on in the 12 months prior to pathway implementation. A questionnaire examining patient-based outcomes and perceptions was completed 6 weeks after surgery. From November 2001 through November 2003, 49 patients underwent primary laparoscopic foregut surgery, 27 before and 22 after pathway implementation. There were no differences in age, gender, procedure, or ASA Class. Parenteral opioid use diminished significantly without compromising the patients' perceived pain control. The number of patients undergoing postoperative investigations diminished, as did length of stay. Of the 20 post-pathway patients completing satisfaction questionnaires, 95% were satisfied or very satisfied with their care during admission. Pathway implementation resulted in a significant reduction in direct postoperative hospital costs. A clinical pathway for laparoscopic foregut surgery was successfully implemented in a single-payer system, resulting in decreased utilization of hospital resources while maintaining high patient satisfaction.

Adult↗
PubMed2002

Guiding practice improvements in pediatric surgery using multidisciplinary clinical pathways.

Clinical pathways guide the evaluation and care of patient populations and can advance the strategic initiatives of the organization as well. To meet external and internal demands, this organization developed pathways to reduce variability in practice, integrate available evidence into care delivery, improve care coordination and documentation, increase efficiencies, and provide outcomes data to consumers and payers. The authors highlight processes and outcomes of some of the organization's surgical pathways, including guidelines for children with second degree burns grafted with TransCyte, those children hospitalized for tonsillectomy or adenoidectomy, appendectomies, atrial and ventricular septal defects, and percutaneous endoscopic gastrostomy or surgical gastrostomy procedures.

Appendectomy↗