Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “Critical Pathways”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 1,783 records · Page 99Linked to original sources
PubMed2004

Role of a clinical facilitator in introducing an integrated care pathway for the care of the dying.

Integrated care pathways (ICPs) have been developed as a tool for improving end-of-life care. The Liverpool Care Pathway for the Dying (LCP) is a multidisciplinary and evidence-based approach to caring for the dying person. At Wythenshawe hospital a clinical facilitator was appointed to facilitate the introduction of the LCP. This full-time post, which existed for 18 months, involved supporting and educating staff about the pathway. The LCP is now used through the general surgical and medical wards and acute and regional coronary care units. This article reflects on the different aspects of the role and the development of the project.

Communication↗
PubMed1998

Provider overhauls pathway procedures to improve outcomes analysis, care efficiency.

Revamping your clinical pathways to make them even more efficient and effective. Anne Arundel Medical Center's successful total hip/total knee replacement pathway has already slashed length of stay 48%, but officials weren't satisfied. They've redesigned the pathway's documentation process to get consistent data for accurately measuring patient outcomes--and have improved efficiency and patient care and education as well. Find out how the new system works and why there's always room for improvement.

Arthroplasty, Replacement, Hip↗
PubMed1998

When the well runs dry: making the switch to disease management.

If you've shortened lengths of stay and cut costs as much as possible short of jeopardizing patient care, it may be time to take what some experts consider the next step beyond traditional case management: hospital-based disease management. Disease management involves not merely making a few process improvements but actually changing the underlying structure of how care is provided, particularly for patients with chronic conditions. Although clinical pathways can help in making the transition to a disease management approach, the most important factor to consider is how to get everyone--both within your facility and along the continuum--on the same page when it comes to managing chronically ill patients.

Case Management↗
PubMedDate not supplied

Judging the effectiveness of clinical pathways for pneumonia: the role of risk adjustment.

CONTEXT: Although observational studies suggest that clinical pathways may decrease costs and improve quality in hospitalized patients with community-acquired pneumonia, inferences from these studies are limited by potential selection bias and inadequate case-mix adjustment. OBJECTIVE: To compare the assessment of a clinical pathway for community-acquired pneumonia with and without adjusting for patient characteristics and disease severity. DESIGN: Retrospective cohort study. PATIENTS AND SETTING: Consecutive series of adult patients admitted with clinical diagnosis of community-acquired pneumonia, treated with either a clinical pathway (which included guidelines for antibiotics, tests, and ancillary care) or usual care. MAIN OUTCOME MEASURES: Total hospital charges, length of stay, clinical deterioration (requiring mechanical ventilation or intensive care unit transfer), and in-hospital mortality. We used multiple linear and logistic regression to adjust for patient case mix. RESULTS: Compared with patients receiving usual care (n = 275), patients in the pathway group (n = 97) were more likely to be treated by family physicians than specialists and had lower pneumonia severity scores. In the unadjusted analysis, total hospital charges were lower among pathway patients ($2456; 95% CI, $175 to $4737; P = 0.04); in the adjusted analysis, the difference in total charges was smaller (average reduction $1807; CI, $4164 lower to $549 higher; P = 0.13). In the unadjusted analysis, length of stay was lower among pathway patients (1.8 days lower; CI, 3.9 lower to 0.4 higher; P = 0.12); in the adjusted analysis, the difference in length of stay was smaller (0.9 days lower; CI, 3.2 lower to 1.3 higher; P = 0.4). Although unadjusted analysis showed significantly lower in-hospital mortality in pathway patients, this difference was not confirmed in the adjusted analysis. CONCLUSIONS: Clinical pathways may reduce costs and improve quality of care in community-acquired pneumonia. In nonrandomized studies, however, selection bias and case-mix differences may explain some of the apparent effectiveness.

Adult↗
PubMed2005

[Clinical pathway for long term home cares].

New tools of clinical pathway for long term home cares (care pathway) and new anamnesis charts on admission were introduced. These tools were based on Takeuchi's assessment methods. I describe that these tools make possible to develop collaborative works (team care) of co-medical staffs and promote a safe and rapid discharge from hospital.

Critical Pathways↗
PubMed2006

Regulation of eukaryotic initiation factor 4E by converging signaling pathways during metabotropic glutamate receptor-dependent long-term depression.

Long-term depression (LTD) is an activity-dependent decrease in synaptic efficacy that can be induced in hippocampal area CA1 by pharmacological application of the selective group I metabotropic glutamate receptor (mGluR) agonist 3,5-diyhroxyphenylglycine (DHPG). Recent work has demonstrated that DHPG-induced LTD recruits at least two signal transduction pathways known to couple to translation, the mitogen-activated protein kinase kinase (MEK)-extracellular signal-regulated kinase (ERK) signaling pathway and the phosphoinositide 3-kinase (PI3K)-Akt-mammalian target of rapamycin (mTOR) signaling pathway. However, it remains unclear which translation factors are engaged by these two signaling pathways during mGluR-LTD. In this study, we investigated whether the group I mGluRs couple to the cap-dependent translation proteins: Mnk1, eIF4E, and 4E-BP. We found that both the MEK-ERK and PI3K-mTOR signaling pathways are critical for the DHPG-induced regulation of these translation factors. Furthermore, we demonstrate that increasing eIF4F complex availability via the genetic elimination of 4E-BP2 can enhance the degree of LTD achieved by DHPG application in an ERK-dependent manner. Our results provide direct evidence that cap-dependent translation is engaged during mGluR-LTD and demonstrate that the MEK-ERK and PI3K-mTOR signaling pathways converge to regulate eIF4E activity after induction of DHPG-LTD.

Animals↗
PubMed2006

A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients.

BACKGROUND: We initiated a multidisciplinary clinical pathway targeting patients greater than 45 years of age with more than 4 rib fractures. The purpose of the current study was to evaluate the effect of this pathway on infectious morbidity and mortality. METHODS: This was a prospective cohort study. Data evaluated included patient demographics, injury characteristics, pain management details, lengths of stay, morbidity, and mortality. Univariate and multivariate analyses were performed using a significance level of P < .05. RESULTS: When adjusting for age, injury severity score, and number of rib fractures, the clinical pathway was associated with decreased intensive care unit length of stay by 2.4 days (95% confidence interval [CI] -4.3, -0.52 days, P = .01) hospital length of stay by 3.7 days (95% CI -7.1, -0.42 days, P = .02), pneumonias (odds ratio [OR] 0.12, 95% CI 0.04 to 0.34, P < .001), and mortality (OR 0.37, 95% CI 0.13 to 1.03, P = .06). CONCLUSIONS: Implementation of a rib fracture multidisciplinary clinical pathway decreased mechanical ventilator-dependent days, lengths of stay, infectious morbidity, and mortality.

Aged↗
PubMed2006

Integrated care pathways: the way forward for continence services?

OBJECTIVES: To assess if an integrated care pathway improves the services provided for continence care. STUDY DESIGN: This was a prospective cohort study. At Worcester Royal Hospital, a UK district general hospital, an integrated care pathway was developed for the management of women presenting in primary care with continence problems. Sixty-five women referred through this pathway were compared to women referred directly to outpatients with similar problems. The outcomes compared were the time in days from referral to (1) the first medical contact, (2) diagnosis (3) physiotherapy/continence advisory review and (4) surgery or discharge. Statistical significance of the difference in outcomes was established using the Mann-Whitney U-test. RESULTS: The mean time from referral to first medical contact, urodynamic studies, physiotherapy/continence advisory team review and to surgery or discharge for the direct access patients compared to clinic patients was significantly less (p<0.05). Thirty-five percent (7/20) patients were discharged without seeing a doctor. CONCLUSION: The implementation of integrated care pathways enables a more efficient service provision for patients with incontinence problems. Thirty-five percent of women attending gynaecology outpatient department with incontinence problems could be effectively managed by urogynaecology specialist nurses.

Ambulatory Care Facilities↗
PubMed2006

A clinical pathway for treating pneumonia in the nursing home: part I: the nursing perspective.

OBJECTIVES: This paper examines nursing staff's perspectives on the utility and sustainability of a clinical pathway for treating nursing home residents with pneumonia. DESIGN: A qualitative (case study) design was used. SETTING: Data were collected from 6 nursing homes in Southern Ontario (5 from metro regions and 1 from a nonmetro region). Nursing homes were drawn from a larger randomized controlled trial of a clinical pathway for nursing home-acquired pneumonia conducted between 2001 and 2005. The clinical pathway was designed to assist in the identification, diagnosis, and management of pneumonia, including a decision tool for determining the appropriate location of treatment (hospital versus nursing home). PARTICIPANTS: A total of 7 focus groups and 1 one-on-one interview were conducted between February 2003 and May 2004. Interview data were analyzed using the template style, described by Miller and Crabtree, to identify key themes. FINDINGS: Nurses strongly supported the idea of the clinical pathway and believed that providing pneumonia care in the nursing home was better for the resident. As a result of using the clinical pathway, nurses felt that pneumonia was being identified, diagnosed, and treated earlier, resulting in fewer hospitalizations. In addition to the benefits to resident care, the nurses felt that their skills and knowledge also improved. Nurses generally supported the implementation of the pathway although some concern was expressed about the additional responsibility and resources that would entail. CONCLUSIONS: The implementation of a clinical pathway for treating pneumonia in nursing homes and quick access to a backup clinician are desired by nurses who also believe it will result in better care and fewer hospitalizations of residents.

Aged↗
PubMed1998

Standardized clinical care pathways for major thoracic cases reduce hospital costs.

BACKGROUND: Standardized clinical care pathways have been developed for postoperative management in an attempt to contain costs in an era of rising health care costs and limited resources. The purpose of this study was to assess the effect of these pathways on length of stay, hospital charges, and outcome for major thoracic surgical procedures. METHODS: All anatomic lung (segmentectomy, lobectomy, and pneumonectomy) and partial and complete esophageal resections performed from July 1991 to July 1997 were retrospectively analyzed for length of stay, hospital charges, and outcome. A prospectively developed database was used. Clinical care pathways were introduced in March 1994. Comparisons were made between the procedures performed before (group I) and after (group II) pathway implementation. Common to both pathways are early mobilization and prudent x-ray and laboratory analysis. In addition, the pathway for esophagectomies emphasizes overnight intubation with 24-hour intensive care unit care, and staged diet advancement. The discharge goal was postoperative day 10. For lung resection the emphasis is early postoperative extubation with overnight intensive care unit management. The discharge goal was postoperative day 7. RESULTS: Group I esophagectomies (n = 56) had significantly greater hospital charges compared with group II (n = 96) ($21,977 +/- $13,555 versus $17,919 +/- $5,321; p < 0.04, in actual dollars) and ($29,097 +/- $18,586 versus $19,260 +/- $6,000; p < 0.001, in dollars adjusted for inflation) and greater length of stay (13.6 +/- 6.9 versus 9.5 +/- 2.8 days; p < 0.001). Group I lung resections (n = 185) had a significantly greater length of stay compared with group II (n = 241) (8.0 +/- 6.2 versus 6.4 +/- 3.8 days; p < 0.002); although charges trended downward ($13,113 +/- $10,711 versus $12,404 +/- $7,189; not significant) in actual dollars, charges were significantly less in dollars adjusted for inflation ($17,103 +/- $13,211 versus $13,432 +/- $8,056; p < 0.01). The most significant decreases in charges for esophagectomies were in miscellaneous charges (61% in dollars adjusted for inflation), pharmaceuticals (60%), laboratory (42%) and radiologic (39%) tests, physical therapy charges (35%), and routine charges (34%). For lung resections the greatest savings occurred for pharmaceuticals (38%), supplies (34%), miscellaneous charges (25%), and routine charges (22%). Mortality was similar (esophagectomies: I, 3.6%; II, 0%; lung resections: I, 0.5%; II, 0.8%; not significant). CONCLUSIONS: Introduction of standardized clinical pathways has resulted in a marked reduction of length of stay for all major thoracic surgical procedures. Total charges were reduced for both esophagectomies (34%) and lung resections (21%) with continued quality of outcome.

Aged↗
PubMed1997

Implementation of a clinical pathway decreases length of stay and hospital charges for patients undergoing total colectomy and ileal pouch/anal anastomosis.

BACKGROUND: Clinical pathways are increasingly being used by hospitals to improve efficiency in the care of certain patient populations; however, little prospective data are available to support their use. This study examined whether using a clinical pathway for patients undergoing ileal pouch/anal anastomosis, a complex procedure in which we had extensive practical experience, affected hospital charges or length of stay (LOS). METHODS: A clinical pathway was developed to serve patients undergoing elective total colectomy and ileal pouch/anal anastomosis. All operations were performed by two attending physicians (J.E.F., M.S.N.). Before implementation, 10 pilot patients were prospectively monitored to ensure that hospital charges were accurately generated. In addition, charge audits were performed by an outside agency to verify the accuracy of the hospital bills. The pathway was then implemented, and 14 patients were prospectively analyzed. RESULTS: In all patients the principal diagnosis was ulcerative colitis, with the exception of three patients with familial polyposis. Mean external audit charges were within 2% of the hospital bills; therefore the hospital bills were used in all calculations. The mean LOS decreased from 10.3 days to 7.5 days (p = 0.046) for patients on the pathway versus pilot patients. Mean hospital charges also decreased significantly, from $21,650 to $17,958 per patient (p = 0.005). CONCLUSIONS: Implementation of a clinical pathway, even for an operation in which the surgeon has much experience, is an effective method for reducing LOS and charges for patients. This is likely the result of interdisciplinary cooperation, elimination of unnecessary interventions, and streamlined involvement of ancillary services. These results support the development of clinical pathways for procedures that involve routine preoperative and postoperative care. In addition, the benefits of clinical pathways should increase proportionally with increasing case volume for a particular procedure.

Adenomatous Polyposis Coli↗
PubMed1998

Factors associated with referral to psychiatric care by general practitioners compared with self-referrals.

BACKGROUND: The gatekeeper function of the general practitioner (GP) in the pathway to specialized psychiatric services was investigated in this study, which is part of the Nordic Comparative Study on Sectorized Psychiatry. The question addressed in this paper is whether different sociodemographic and clinical factors as well as factors related to service utilization are associated with referral from the GP compared with self-referrals (including referrals from relatives). METHODS: The study comprised a total of 1413 consecutive patients, admitted during 1 year to five psychiatric centres in four Nordic countries. The centres included in this study were those that accepted non-medical referrals. Only new patients (not in contact with the service for at least 18 months) were included. RESULTS: Increasing age was the only sociodemographic factor significantly associated with referral by the GP. The clinical factors (psychosis, being totally new to psychiatry and being in need of in-patient treatment) and some treatment characteristics (planned out-patient treatment and involuntary in-patient treatment), were all significantly associated with referral by the GP. Some indication was found that self-referred patients have shorter episodes of care. CONCLUSIONS: The findings were remarkably stable across the different centres indicating a general pattern. This study extends previous work on the role of GPs in the pathway to specialized psychiatric services and indicates that the GP has an important gatekeeper function for the most disabled patients.

Adolescent↗
PubMed2005

Cost unit accounting based on a clinical pathway: a practical tool for DRG implementation.

Setting up a reliable cost unit accounting system in a hospital is a fundamental necessity for economic survival, given the current general conditions in the healthcare system. Definition of a suitable cost unit is a crucial factor for success. We present here the development and use of a clinical pathway as a cost unit as an alternative to the DRG. Elective coronary artery bypass grafting was selected as an example. Development of the clinical pathway was conducted according to a modular concept that mirrored all the treatment processes across various levels and modules. Using service records and analyses the process algorithms of the clinical pathway were developed and visualized with CorelTM iGrafix Process 2003. A detailed process cost record constituted the basis of the pathway costing, in which financial evaluation of the treatment processes was performed. The result of this study was a structured clinical pathway for coronary artery bypass grafting together with a cost calculation in the form of cost unit accounting. The use of a clinical pathway as a cost unit offers considerable advantages compared to the DRG or clinical case. The variance in the diagnoses and procedures within a pathway is minimal, so the consumption of resources is homogeneous. This leads to a considerable improvement in the value of cost unit accounting as a strategic control instrument in hospitals.

Accounting↗
PubMed1999

Aspirin administration for cardiac-related acute chest pain/angina: increased use in Medicare patients.

BACKGROUND: Coronary heart disease (CHD), the leading cause of death in the United States, accounted for approximately 490,000 deaths in 1993. Angina pectoris, a manifestation of CHD, accounted for 13,586 Medicare discharges in 1993 in Texas. A pilot project showed aspirin prophylaxis that reduces cardiovascular morbidity and mortality in individuals with acute angina is underused. Texas Medical Foundation collaborated with 10 acute-care facilities to improve aspirin prophylaxis. METHODS: Collaborators assessed processes of care and implemented clinical pathways to improve aspirin administration. Data were abstracted from medical records before and after pathway implementation to evaluate impact. RESULTS: Aspirin administration during hospital stay increased 10.8%, aspirin administration on discharge increased 11.7%, and average time from arrival to aspirin administration decreased 2.9 hours. CONCLUSIONS: Results suggest collaborator-implemented clinical pathways significantly improved care received by Medicare patients admitted for cardiac-related acute chest pain/angina. Data suggest room for further improvement.

Acute Disease↗
PubMedDate not supplied

The next frontier in clinical pathways. The journey to outcomes management.

The Children's Memorial Hospital, a 265-bed pediatric hospital in Chicago, Illinois, is a leader in pediatric clinical pathway development. Significant improvements in care coordination and cost savings have been realized from the 14 pathways implemented to date. Use of a project management methodology and adaptation of continuous quality improvement tools for pathway development have proven effective to streamline and standardize this process. Despite its success in pathway development, Children's Memorial Hospital has realized the need to go further. It is necessary to measure outcomes--real clinical, patient outcomes--not just financial or utilization outcomes. Solid comparative data from which practice changes can be made are needed. Additional ways must be found to facilitate movement along the care continuum. Pathways must be used consistently. This article will outline the process Children's Memorial Hospital used and share the development tools that have been implemented. Children's Memorial Hospital's vision for the future and the technology designed to realize that vision are delineated.

Case Management↗
PubMed1997

Care pathway reduces hospitalizations and cost for hemodialysis vascular access surgery.

Hemodialysis vascular access-related hospitalizations account for more than 20% of United States end-stage renal disease (ESRD) hospitalizations, with an annual cost approximating $675 million. Limiting access-related costs while delivering similar degrees of quality care thus would enhance alternative utilization of ESRD funding. We implemented a vascular access care pathway emphasizing coordinated patient evaluation and outpatient surgery to determine whether such an intervention affected outcomes associated with vascular access surgery. Data examining hospitalization and vascular access surgery charges, complications, and patient satisfaction (determined by questionnaire) were analyzed, comparing patients who underwent vascular access surgery in 1994 and 1995 as inpatients (non-care pathway patients) and patients who underwent vascular access surgery via the care pathway in 1995. Inpatient days declined in 1995 (1994: 582 days; 1995: 85 days; P < 0.03) and the average charges per patient for the care pathway cohort were significantly less than charges per patient in 1994 and charges for non-care pathway patients in 1995 (1994 patients: $10,524 +/- $5,209; 1995 non-care pathway patients: $11,196 +/- $5,806; 1995 care pathway patients: $4,686 +/- $2,912/patient; P < 0.02). Incidence rates for major (life-threatening) complications were not significantly different between 1994 patients and care pathway patients in 1995. However, the 1995 non-care pathway patients had a higher incidence of major complications (15.4%). Forty-seven repeat access procedures were performed in 29 patients in 1994 versus 35 repeat access procedures in 22 care pathway patients in 1995, and 12 repeat access procedures were performed in eight non-care pathway patients in 1995. Finally, a majority of the patients entered into the care pathway who responded to a survey stated that they were satisfied with access surgery via the care pathway. These data suggest that a vascular access care pathway can reduce hospital days and costs while achieving acceptable outcomes for access surgery.

Ambulatory Surgical Procedures↗
PubMed2002

Effectiveness of a croup clinical pathway in the management of children with croup presenting to an emergency department.

OBJECTIVE: The aim of this study was to evaluate the safety and effectiveness of a clinical pathway for croup in an emergency department (ED). METHODOLOGY: This before-and-after intervention study on all consecutive children aged 6 months to 10 years who presented to our ED with moderate/severe croup was conducted over a 6-month period. Children with a clinical croup score (CSS) of 2 or more and resting stridor were considered eligible for entry into the study. Children were treated with either oral dexamethasone, or a combination of oral dexamethasone suspension and nebulized adrenaline. Children were clinically assessed, observed in the emergency short-stay ward and discharged or admitted according to the clinical pathway. The following outcomes were measured: admission rates, hospital re-presentation, length of stay, and adverse clinical events. Children in the post-intervention group were followed up by telephone within 48 h of discharge. RESULTS: There were 157 patients recruited in the pre-intervention group and 110 in the post-intervention group. Significant reductions were reported in the length of stay (18.9 h compared with 5.2 h), hospital admission (52.9% compared with 18.0%) and intensive care admission (10.2% compared with 0.0%) after the introduction of the croup clinical pathway. No children in the study experienced an adverse clinical event. Follow-up interviews of parents indicated that the new treatment strategy was well received. CONCLUSION: The use of the croup clinical pathway in the ED is safe and effective in guiding consistent management, resulting in reduced admission rates, earlier discharge home, and no reported adverse events.

Anti-Inflammatory Agents↗
PubMed1999

Implementation of a patient-family pathway: effects on patients and families.

The purpose of this study was to discover whether implementation of a patient-family pathway with patients and families undergoing coronary artery bypass graft (CABG) surgery impacted anxiety, information with care planning, and patient length of stay. Using an experimental design, a sample of 60 patients and family members was studied. Each patient and his or her designated family member received either the patient-family pathway or the hospital's standard care planning. Findings indicated no statistically significant differences in state anxiety or information with care planning between patients and family members receiving the patient-family pathway and those receiving standard care planning. There was no statistically significant difference in length of stay between the two patient groups. The results indicate that the CABG patient-family pathway has limited value to patients and families as measured in this study. Resources can be real-located to other uses that may have a more positive impact on the patient and family experience.

Adult↗