Taking the right pathway. Critical pathways are a road map to care.
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Cost Control↗
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Opportunities for pharmaceutical care with critical pathways.
Critical pathways are multidisciplinary tools designed to improve patient care and efficiency. Almost every path requires some type of pharmacotherapeutic intervention, from selection of surgical prophylaxis to management of anticoagulation. Pharmacists should become involved with the critical pathway process because it offers an excellent opportunity to incorporate pharmaceutical care and to meet Joint Commission on Accreditation of Healthcare Organization compliance criteria.
Clinical Protocols↗
Expanding the use of critical pathways in critical care.
Critical pathways are known to decrease the patient's length of stay while simultaneously using resources effectively and efficiently. Several additional functions of critical pathways exist: pathways are used as tools for teaching; to predict and prevent complications; streamline charting; and anticipate staffing needs. These and other functions of critical pathways are described as they apply to critical care patients.
Clinical Protocols↗
Critical pathway experience at Cedar-Sinai Medical Center.
Critical pathways provide an excellent tool for promoting multidisciplinary efforts to develop optimal, cost-competitive plans for managing patient care. The pharmacy department can play a variety of roles in developing and implementing critical pathways. In advocating optimal drug selection and monitoring, pharmacists can help their institutions reduce costs while maintaining or improving quality of care.
California↗
Marketing critical pathways in critical care.
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Critical Care↗
Critical pathways.
A critical Pathway (CP) is a clinical management tool that helps medical care providers coordinate the delivery of patient care for a particular case type or condition. As a guide to usual treatment patterns, a CP gives a view of the "big picture." The CP usually recommends a total treatment regimen. Treatment regimens are formulated through the consensus of a multi-disciplinary collaboration of all those involved in a patient's care. If developed and implemented properly, critical paths can lead to desirable outcomes for the patient and improved operating effectiveness/efficiency for the healthcare facility. Components of CPs often include protocols, algorithms, and clinical practice guidelines. Metrics, bench-marks, compliance, and variances become common terms among members of the healthcare team. Although CPs have gained wide acceptance as inpatient management tools, they are rapidly being sought for outpatient settings as well. This article details the CP process and cites examples of two hospitals that have used CPs to reduce length of stay and cut costs.
Anesthesiology↗
HIV critical pathway can make critical difference.
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AIDS-Related Opportunistic Infections↗
Being led down the critical pathway: a perspective on the importance of care managers vs critical pathways for patients requiring prolonged mechanical ventilation.
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Case Management↗
A critical evaluation of critical pathways in head and neck cancer.
BACKGROUND: Critical pathways have been purported to decrease resource utilization in the management of head and neck cancer. Prior reports have documented shorter lengths of stay (LOS) for pathway patients than for historical cohorts. OBJECTIVE: To critically evaluate the impact of critical pathways on LOS after laryngectomy. DESIGN: Length-of-stay trends of 2 concurrent observational cohorts of laryngectomy patients (September 1992 to February 1999) were compared, 1 at each of 2 medical centers. One center instituted a critical pathway for laryngectomy patients in February 1997; the other never used such pathways. In addition, we examined the independent impact of the critical pathway at the pathway institution after controlling for date of laryngectomy (which reflected temporal trends) and other confounding variables. RESULTS: Both centers experienced reductions in LOS after February 1997, but there was no statistically significant difference between the reductions (1.9 days at the pathway center vs 1.5 days at the nonpathway center; P>.05). Multivariable linear and linear spline regression models demonstrated that the use of critical pathways at the pathway institution had no statistically significant impact on LOS after controlling for the date of laryngectomy. CONCLUSIONS: Pathway implementation has a limited direct impact on LOS in relatively low-volume procedures such as laryngectomy. Although pathways may influence utilization trends, their impact is likely mediated by the development and educational process that accompanies pathway adoption rather than implementation of the pathway itself. The inclusion of temporal trends and contemporary cohorts provides substantial insight into the effectiveness of critical pathways.
Aged↗
Critical pathways. A systematic review.
Critical pathways are care plans that detail the essential steps in patient care with a view to describing the expected progress of the patient. The authors' review of the literature suggest the use of critical pathways reduces the cost of care and the length of patient stay in hospital. They also have a positive impact on outcomes, such as increased quality of care and patient satisfaction, improved continuity of information, and patient education.
Benchmarking↗
[Critical pathways and computerized multidisciplinary documentation system].
Critical pathways are widely adopted by many large hospitals around the world in order to provide high-quality patient treatment. The development of critical pathways is a lengthy process, and may require the collaboration among physicians, nurses, and staffs in a hospital. The development and implementation of critical pathways at Kanto Medical Center and the transition to a computerized multidisciplinary documentation system took place between 2000 and 2001. The article describes the process of creating the automated documentation system to support the critical pathways. The advantages, pitfalls learned in this integration experience are described.
Critical Pathways↗
Critical pathways as an essential part of a disease management program.
Disease management is becoming a common tool utilized by health systems for managing patients with chronic diseases. Part of the success of disease management can be attributed to the use of critical pathways. Critical pathways are the tools that prompt decisions to be made based on clinical practice guidelines. In addition to allowing nursing case managers to have significant input into patient treatment decisions, critical pathways assist disease management programs in realizing significant cost savings as well as assisting in outcomes management activities.
Adult↗
Use of critical pathways to improve efficiency: a cautionary tale.
BACKGROUND: Critical pathways are healthcare management plans that specify patient goals and the sequence and timing of actions necessary to achieve these goals with optimal efficiency. More than 80% of hospitals in the United States use critical pathways for at least some of their patients. Unfortunately, critical pathway effectiveness in improving clinical efficiency is unclear. OBJECTIVES: To assess whether critical pathways have been successful in reducing patient length of stay (LOS) and resource utilization in our tertiary-care academic medical center. STUDY DESIGN: A before-and-after observational study using multivariate linear regression analyses. METHODS: We identified all critical pathways initiated in our medical center between 1993 and 1996 in which at least 50 adult patients would be evaluated in the year preceding and succeeding pathway implementation; 13 pathways satisfied these inclusion criteria. Using a before-and-after design, multivariate linear regression was used to evaluate each pathway's effect on average monthly LOS and resource utilization after adjusting for case mix and secular trends. RESULTS: Three of the 13 pathways were associated with a statistically significant immediate decrease in inpatient LOS: acute myocardial infarction (20.7% decrease; P = .001), cesarean section (14.6% decrease; P = .03), and kidney transplantation (24.5% decrease; P = .003). Only 1 pathway, percutaneous transluminal coronary angioplasty (PTCA), produced a statistically significant decrease in LOS slope (a decrease of 5.2% per month; P = .001). Two pathways were accompanied by a statistically significant immediate reduction in ancillary resource utilization: kidney transplantation (26.4% decrease; P = .001) and community-acquired pneumonia (21.8% decrease; P = .002). Only the PTCA pathway produced a statistically significant decrease in resource utilization slope during the 12-month follow-up period (a decrease of 8.4% per month; P < .001). CONCLUSIONS: Although some pathways did reduce LOS or resource utilization or both, most pathways reduced neither. Because substantial resources must be expended on pathway development, implementation, and maintenance, future efforts should be placed on further evaluating the effectiveness of critical pathways and understanding the reasons behind their success or failure before additional resources are consumed for this management strategy.
Critical Pathways↗
Analysis of a critical pathway in osteoplastic flap for frontal sinus obliteration.
OBJECTIVES: A critical pathway was applied to patients undergoing osteoplastic flap (OPF) for frontal sinus obliteration to determine whether efficiency could be improved. STUDY DESIGN: A retrospective review of consecutive OPF procedures (n = 51) performed between 1992 and July 1997 was conducted. METHODS: The patient groups were subdivided into those who underwent OPF alone and those who had endoscopic sinus procedures performed in addition to OPF. Comparisons were made between the precritical pathway and post-critical pathway groups, specifically noting operative time, total operating room (OR) time, estimated blood loss (EBL), length of hospital stay, and costs. We used a critical pathway that was developed for endoscopic sinus procedures at our institution through a multidisciplinary team approach. Preoperative evaluation and testing, intraoperative equipment and medications, and postoperative care including follow-up clinic visits were all standardized. An unpaired, two-tailed Student t test was used to evaluate the data. RESULTS: Statistically significant (P<.05) reductions in operative times, total OR time, EBL, and length of hospital stay were observed in the post-critical pathway group who underwent endoscopic sinus procedures as well as OPF. Costs to the OR were reduced 29% and 15% for OPF and for OPF with endoscopic surgery, respectively. Patient costs were reduced 5% and 4% in these groups, respectively. CONCLUSIONS: With implementation of effective critical pathways, significant decreases in length of stay are seen, and cost reductions can be realized through the improved efficiency, shortened OR times, and decreases in redundancy of ordering materials.
Bone Transplantation↗
ASHP Guidelines on the Pharmacist's Role in the Development, Implementation, and Assessment of Critical Pathways.
Because pharmacotherapy is a central component of many critical pathways, pharmacists should take leadership roles in their development, implementation, and assessment. Pharmacists can improve the development of critical pathways by ensuring the evidence-based selection of medications, establishing measures for monitoring patients for drug efficacy and adverse effects, and evaluating the proposed critical pathway for patient safety. Pharmacists can improve the implementation of critical pathways by documenting processes and outcomes, ensuring proper patient selection and medication use, monitoring patients for drug efficacy and adverse effects, and providing for continuity of care. Pharmacists can improve the assessment of critical pathways by measuring and analyzing processes and outcomes, disseminating the results of those analyses, and reviewing the critical pathways' pharmacotherapy to keep pace with changes in best practices.
Continuity of Patient Care↗
Critical pathways for acute myocardial infarction.
Critical pathways are standardized protocols for optimizing and streamlining patient care. They are important in the management of patients with acute myocardial infarction, many of whom do not receive evidence-based therapies. Several studies have demonstrated that the development and implementation of critical pathways that follow published guidelines and are tailored to the needs and resources of each institution result in increased use of evidence-based therapies, such as aspirin and beta-blockers, and is associated with decreased mortality. Use of these protocols has also been shown to reduce unnecessary therapy and under- or overutilization of certain procedures, thereby resulting in more cost-effective treatment.
Adrenergic beta-Antagonists↗
Transsphenoidal resection of pituitary adenoma: using a critical pathway.
The use of a transsphenoidal critical pathway can be a vital tool for critical care nurses in anticipating complications and improving patient outcomes. Complications such as diabetes insipidus and cerebrospinal fluid leak associated with posttranssphenoidal patients may result in prolonged hospitalization and worsened functional outcome. Implementing a transsphenoidal critical pathway for these patients can guide their care and alert critical care nurses to potential complications and their prevention and/or treatment.
Adenoma↗
Critical pathway management of unstable angina.
The critical pathway for UA is a multidisciplinary management tool designed to assist in expediting the treatment and evaluation of this frequent clinical syndrome. No critical pathway or practice guideline will meet the needs of all patients, and flexibility for patient variations and physician judgment is mandatory. Prediction tools and other facilitators cannot replace and must not impede the thoughtful assessment of complex clinical situations. Numerous factors, occasionally social or political in nature, impact on patient treatment strategies and the application of interventions. It is our hope that the Unstable Angina Critical Pathway will form a foundation for further innovation and cooperative effort toward optimizing the management of patients with acute ischemic syndromes.
Acute Disease↗