Caremaps, Critical Paths, etc.  September 1999-Present, Part 1

     1.    Corcoran, W. E., & Durham, C. F. (2000). Quality of life as an outcome-based evaluation of coronary artery bypass graft critical paths using the SF-36. Qual Manag Health Care, 8(2), 72-81.
Abstract: The Medical Outcomes Study Short Form 36 (SF-36) may prove to be a useful tool to evaluate the impact of critical paths (path) on discharged patients. Its ability to measure effects of the path must first be evaluated. The purposes of this study are to evaluate the path using the SF-36, and evaluate its ability to measure path outcomes. Subjects cared for through a coronary artery bypass critical path completed the SF-36 and were compared against a similar baseline sample. The specificity to measure the path influence was inconclusive, because comorbidities and activity restrictions present misleading results in the measurement of disability in its current use.

     2.    Roddy, S. P., Estes, J. M., Kwoun, M. O., O'donnell, T. F. Jr, & Mackey, W. C. (2000). Factors predicting prolonged length of stay after carotid endarterectomy [In Process Citation]. J Vasc Surg, 32(3), 550-4.
Abstract: BACKGROUND: Over the last several years, implementation of critical pathways in patients undergoing carotid endarterectomy has decreased postoperative length of stay significantly. Discharge the day after surgery has become commonplace in many centers, including our own. Unfortunately, managed care may interpret this refinement as a standard of care and limit reimbursement or even disallow admissions extending beyond 1 day. We therefore examined our carotid registry to identify risk factors associated with postoperative length of stay exceeding 1 day. METHODS: We retrospectively reviewed all patients undergoing carotid endarterectomy at our academic center from May 1996 through April 1999. Combined procedures and patients undergoing subsequent noncarotid-related procedures on those admissions were excluded. The charts were inspected for atherosclerosis risk factors, including sex and age, specific attending surgeon, side of the surgery, use of intravenous vasoactive drugs, actual preoperative blood pressure, and presence of neurologic symptoms or postoperative complications. Multiple regression analysis was performed on all collected variables. Statistical significance was inferred for P less than.05. RESULTS: A total of 188 patients met the study criteria and had complete, retrievable medical records. A mean postoperative length of stay of 1.65 +/- 0.08 days and a mean total length of stay of 2.17 +/- 0.14 days were observed. Fifty-seven percent of patients went home the day after surgery. There was a 1.6% stroke-mortality rate. Significant predictors of a prolonged stay, listed in order of decreasing importance on the basis of their calculated contribution to prolonging the postoperative length of stay, are as follows (P value; beta coefficient): postoperative complications (<.0001; 1.03), age > 79 years (.008; 0.547), diabetes mellitus (.011; 0.407), female sex (.007; 0.398), and intravenous vasodilator requirement (. 035; 0.382). Other atherosclerosis risk factors, prior neurologic symptoms, the postoperative use of vasopressors, and reoperative surgery did not contribute to extended length of stay. CONCLUSIONS: Discharge on the first postoperative day is feasible in many, but not all, patients undergoing carotid endarterectomy. Our data help define subsets of patients at risk for prolonged postoperative stay. Targeting these subsets for preoperative medical and social interventions may allow safe early discharge more frequently.

     3.    Roddy, S. P., Estes, J. M., Kwoun, M. O., O'donnell, T. F. Jr, & Mackey, W. C. (2000). Factors predicting prolonged length of stay after carotid endarterectomy. J Vasc Surg, 32(3), 550-4.
Abstract: BACKGROUND: Over the last several years, implementation of critical pathways in patients undergoing carotid endarterectomy has decreased postoperative length of stay significantly. Discharge the day after surgery has become commonplace in many centers, including our own. Unfortunately, managed care may interpret this refinement as a standard of care and limit reimbursement or even disallow admissions extending beyond 1 day. We therefore examined our carotid registry to identify risk factors associated with postoperative length of stay exceeding 1 day. METHODS: We retrospectively reviewed all patients undergoing carotid endarterectomy at our academic center from May 1996 through April 1999. Combined procedures and patients undergoing subsequent noncarotid-related procedures on those admissions were excluded. The charts were inspected for atherosclerosis risk factors, including sex and age, specific attending surgeon, side of the surgery, use of intravenous vasoactive drugs, actual preoperative blood pressure, and presence of neurologic symptoms or postoperative complications. Multiple regression analysis was performed on all collected variables. Statistical significance was inferred for P less than.05. RESULTS: A total of 188 patients met the study criteria and had complete, retrievable medical records. A mean postoperative length of stay of 1.65 +/- 0.08 days and a mean total length of stay of 2.17 +/- 0.14 days were observed. Fifty-seven percent of patients went home the day after surgery. There was a 1.6% stroke-mortality rate. Significant predictors of a prolonged stay, listed in order of decreasing importance on the basis of their calculated contribution to prolonging the postoperative length of stay, are as follows (P value; beta coefficient): postoperative complications (<.0001; 1.03), age > 79 years (.008; 0.547), diabetes mellitus (.011; 0.407), female sex (.007; 0.398), and intravenous vasodilator requirement (. 035; 0.382). Other atherosclerosis risk factors, prior neurologic symptoms, the postoperative use of vasopressors, and reoperative surgery did not contribute to extended length of stay. CONCLUSIONS: Discharge on the first postoperative day is feasible in many, but not all, patients undergoing carotid endarterectomy. Our data help define subsets of patients at risk for prolonged postoperative stay. Targeting these subsets for preoperative medical and social interventions may allow safe early discharge more frequently.

     4.    March, L. M., Cameron, I. D., Cumming, R. G., Chamberlain, A. C., Schwarz, J. M., Brnabic, A. J., O'Meara, P., Taylor, T. F., Riley, S., & Sambrook, P. N. (2000). Mortality and morbidity after hip fracture: can evidence based clinical pathways make a difference? J Rheumatol, 27(9), 2227-31.
Abstract: OBJECTIVE: To evaluate whether evidence based clinical pathways for acute management of hip fracture have an effect on patient care, short term mortality, or residential status. METHODS: Observational cohort study comparing management, as determined by medical record review, and outcomes, as determined by telephone followup 4 months post-fracture, before (n = 455) and after (n = 481) clinical pathway implementation within pathway hospitals as well as between patients admitted to hospitals with (n = 2) and without (n = 4) pathways. RESULTS: Mean age was 82 years, 80% were women and 30% were admitted from nursing homes. Significant improvement in best practice as recommended by evidence based clinical guidelines was evident in pathway hospitals for most components of care. However, compliance was variable and nonpathway hospitals performed better for some (use of spinal anesthesia, avoidance of urinary catheters). After adjusting for potential confounders, no difference was found in 4 month mortality between the pathway (17.6%) and non-pathway (16.8%) patients (OR 0.8, 95% CI 0.5-1.5). There was a nonsignificant reduction in median acute care hospital length of stay of 1 day (p = 0.200) for non-nursing home patients and a significant reduction of 1 day (p = 0.038) for nursing home patients in the pathway hospitals. There was a nonsignificant decrease in admission rates for new patients to nursing homes in pathway hospitals (18.5%) compared to non-pathway hospitals (24.3%) (OR 0.5, 95% CI 0.3-1.1). CONCLUSION: Clinical pathways were associated with increased use of evidence based best practice, some reduction in acute hospital length of stay, but no significant effect on 4 month mortality or residential status. Their development and maintenance were resource intensive and further work on the implementation of evidence based guidelines is needed to determine whether they can influence patient outcomes.

     5.    Doering, L. V., Esmailian, F., & Laks, H. (2000). Perioperative Predictors of ICU and Hospital Costs in Coronary Artery Bypass Graft Surgery. Chest, 118(3), 736-743.
Abstract: Study objective: Economic forces have precipitated intense interest in cost-saving practices for patients undergoing coronary artery bypass grafting (CABG). While several preoperative variables have been implicated in higher costs, few studies have included perioperative factors. This study evaluated the predictive power of a preoperative mortality risk measurement (Parsonnet score) and of early extubation (</= 6 h from ICU admission) in determining ICU and hospital costs. DESIGN: Multivariate correlational design. SETTING: University hospital in a large metropolitan area. PATIENTS: All patients (n = 116) undergoing isolated CABG during a 6-month period were studied after the introduction of a clinical pathway. Measurements and results: Clinical data were collected. Costs data were obtained retrospectively from the institutional data system and were derived from individual patient charges by application of department-specific cost-to-charge ratios. In multivariate logistic regression, Parsonnet score (per point odds ratio [OR], 1.09; confidence interval [CI], 1.03 to 1.17), in-hospital coronary angiography (OR, 3.51; CI, 1.23 to 10.01), delayed extubation (OR, 4.59; CI, 1.29 to 16.29), and presence of arrhythmia (OR, 3.50; CI, 1.15 to 10.64) were independent predictors of ICU costs. Only Parsonnet score (OR, 1.09; CI, 1.03 to 1.15) and cardiopulmonary bypass time (OR, 1.01; CI, 1.00 to 1.02) were independent predictors of hospital costs. CONCLUSIONS: The Parsonnet score is a useful indicator of both ICU and hospital costs. Early extubation is associated with decreased ICU costs, but is not independently predictive of hospital costs.

     6.    Chung, D. C. (2000). The genetic basis of colorectal cancer: insights into critical pathways of tumorigenesis [In Process Citation]. Gastroenterology, 119(3), 854-65.

     7.    Chung, D. C. (2000). The genetic basis of colorectal cancer: insights into critical pathways of tumorigenesis. Gastroenterology, 119(3), 854-65.

     8.   Williams, B. A., Kentor, M. L., Williams, J. P., Figallo, C. M., Sigl, J. C., Anders, J. W., Bear, T. C., Tullock, W. C., Bennett, C. H., Harner, C. D., & Fu, F. H. (2000). Process analysis in outpatient knee surgery: effects of regional and general anesthesia on anesthesia-controlled time. Anesthesiology, 93(2), 529-38.
Abstract: BACKGROUND: The performance of anesthetic procedures before operating room entry (e.g., with either general or regional anesthesia [RA] induction rooms) should decrease anesthesia-controlled time in the operating room. The authors retrospectively studied the associations between anesthesia techniques and anesthesia-controlled time, evaluating one surgeon performing a single procedure over a 3-yr period. The authors hypothesized that, using the anesthesia care team model, RA would be associated with reduced anesthesia-controlled time compared with general anesthesia (GA) alone or combined general-regional anesthesia (GA-RA). METHODS: The authors queried an institutional database for 369 consecutive patients undergoing the same procedure (anterior cruciate ligament reconstruction) performed by one surgeon over a 3-yr period (July 1995 through June 1998). Throughout the period of study, anesthesia staffing consisted of an attending anesthesiologist medically directing two nurse anesthetists in two operating rooms. Anesthesia-controlled time values were compared based on anesthesia techniques (GA, RA, or GA-RA) using one-way analysis of variance, general linear modeling using time-series and seasonal adjustments, and chi-square tests when appropriate. P < 0. 05 was considered significant. RESULTS: RA was associated with the lowest anesthesia-controlled time (11.4 +/- 1.3 min, mean +/- 2 SEM). GA-RA (15.7 +/- 1.0 min) was associated with lower anesthesia-controlled time than GA used alone (20.3 +/- 1.2 min). CONCLUSIONS: When compared with GA without an induction room for outpatients undergoing anterior cruciate ligament reconstruction, RA with an induction room was associated with the lowest anesthesia- controlled time. Managers must weigh the costs and time required for anesthesiologists and additional personnel to place nerve blocks or induce GA preoperatively in such a staffing model.

     9.    Porter, G. A., Pisters, P. W., Mansyur, C., Bisanz, A., Reyna, K., Stanford, P., Lee, J. E., & Evans, D. B. (2000). Cost and utilization impact of a clinical pathway for patients undergoing pancreaticoduodenectomy. Ann Surg Oncol, 7(7), 484-9.
Abstract: BACKGROUND: When implemented in several common surgical procedures, clinical pathways have been reported to reduce costs and resource utilization, while maintaining or improving patient care. However, there is little data to support their use in more complex surgery. The objective of this study was to determine the effects of clinical pathway implementation in patients undergoing elective pancreaticoduodenectomy (PD) on cost and resource utilization. METHODS: Outcome data from before and after the development of a clinical pathway were analyzed. The clinical pathway standardized the preoperative outpatient care, critical care, and postoperative floor care of patients who underwent PD. An independent department determined total costs for each patient, which included all hospital and physician costs, in a blinded review. Outcomes that were examined included perioperative mortality, postoperative morbidity, length of stay, readmissions, and postoperative clinic visits. RESULTS: From January, 1996 to December, 1998, 148 consecutive patients underwent PD or total pancreatectomy; 68 before pathway development (PrePath) and 80 after pathway implementation (PostPath). There were no significant differences in patient demographics, comorbid conditions, underlying diagnosis, or use of neoadjuvant therapy between the two groups. Mean total costs were significantly reduced in PostPath patients compared with PrePath patients ($36,627 vs. $47,515; P = .003). Similarly, mean length of hospital stay was also significantly reduced in PostPath patients (13.5 vs. 16.4 days; P = .001). The total cost differences could not be attributed solely to differences in room and board costs. Cost and length-of-stay differences remained when outliers were excluded from the analysis. Despite these findings, there were no significant differences between PrePath and PostPath patients in terms of perioperative mortality (3% vs. 1%), readmissions within 1 month of discharge (15% vs. 11%), or mean number of clinic visits within 90 days of discharge (3.3 vs. 3.4 visits). CONCLUSIONS: The establishment of a clinical pathway for PD patients dramatically reduced costs and resource utilization without any apparent detrimental effect on quality of patient care. These findings support the implementation of clinical pathways for PD patients, as well as investigation into pathway care for other complex surgical procedures.

   10.    Nozue, M., Maruyama, T., Imamura, F., & Fukue, M. (2000). [Cost accounting for gastrectomy under critical path--the usefulness of direct accounting of personnel expenses and a guide to shortening hospital stay]. Gan To Kagaku Ryoho, 27(9), 1369-74.
Abstract: In this study, cost accounting was made for a surgical case of gastrectomy according to critical path (path) and the economic contribution of the path was determined. In addition, changes in the cost percentage with changes in number of hospital days were simulated. Basically, cost accounting was done by means of cost accounting by departments, which meets the concept of direct cost accounting of administered accounts. Personnel expenses were calculated by means of both direct and indirect calculations. In the direct method, the total hours personnel participated were recorded for calculation. In the indirect method, personnel expenses were calculated from the ratio of the income of the surgical department to that of other departments. Purchase prices for all materials and drugs used were recorded to check buying costs. According to the direct calculating method, the personnel expenses came to approximately 300,000 yen, total cost was approximately 700,000 yen, and the cost percentage was 59%. According to the indirect method, the personnel expenses were approximately 540,000 yen and the total cost was approximately 940,000 yen, the cost percentage being 80%. A simulation study of changes in the cost with changes in hospital days revealed that the cost percentages were assessed to be approximately 53% in 19 hospital days and approximately 45% in 12 hospital days.

   11.    Nishimura, Y., Mitsutake, N., Nakanishi, S., & Konishi, T. (2000). [Cost analysis on stomach cancer treatment in Japanese hospitals]. Gan To Kagaku Ryoho, 27(9), 1360-8.
Abstract: BACKGROUND: In an effort to further the discussion of DRG/PPS, we performed a coat analysis on stomach cancer cases in Japanese hospitals. We analyzed individual in-patient data (both clinical and financial) to research the amount of variation in treatment and costs. METHODS: The data was taken from two hospitals. In order to compare the daily cost/revenue of each episode of operation/hospitalization, we analyzed the data that was stored for reimbursement purposes by using patient ID numbers. We also simulated the cost/revenue in cases where the length of stay could be shortened with clinical pathways created by Japanese hospitals. RESULTS: (1) There is a common pattern for the operation/hospitalization of stomach cancer cases if the patient's condition, like severity, is well controlled. However, there is still a noticeable difference in the length of stay for patients both before and after the operation. (2) Hospitals are currently losing money by having extended patients' lengths of stay. Simulation results indicate that hospitals can reduce losses, even become profitable, by shortening the patient's length of stay. CONCLUSIONS: The potentiality of implementing a standard treatment process and/or a fixed payment system, like DRG/PPS, is high, because there is a common a pattern among the treatment process. More research must be completed in this area, specifically on the significant variations in lengths of stay and the methodology for standardization of treatment. Furthermore, clinical outcomes research must also be done.

   12.    Muto, M., & Konishi, T. (2000). [Critical paths and economical efficiency on cancer therapy]. Gan To Kagaku Ryoho, 27(9), 1380-9.
Abstract: The critical paths of cancer patient care are discussed. The number of cancer institutes which have introduced critical paths into patient care has been increasing in the past few years. The effect of critical paths is to standardize the patient care process, shorten the length of the hospital stay of cancer patients, reduce the cost of care, have a well-managed cancer care team, and satisfy patients with full information on the care schedule. Combined with clinical practice guidelines, protocols and algorithms, critical paths are a more powerful tool with which to improve the efficiency and quality of cancer patient management in hospital care.

   13.    Luhmann, D., Kohlmann, T., & Raspe, H. (2000). Z Arztl Fortbild Qualitatssich, 94(6), 475-81.
Notes: TRANSLIT/VERNAC TITLE: Stellenwert der Osteodensitometrie im Rahmen von Pravention und Therapie der Osteoporose. Beispiel einer systematischen Verfahrensbewertung in der Medizin (Health Technology Assessment).
Abstract: There is an ongoing controversy concerning the use of bone density measurements within therapeutic and preventive strategies of osteoporosis. Since there are no randomized controlled trials evaluating the effectiveness of bone density measurement with subsequent therapy we used a "critical pathway" model to determine possible benefit of tertiary, secondary and primary preventive strategies utilizing bone density measurement. In a first step data for fracture risk in each group are extracted from the literature. The second step outlines possible benefit from therapeutic studies. It may be estimated that in groups of patients with prevalent fractures use of bone density measurement and therapy according to bone density values may reduce fracture rates up to 30%. Bone density measurements performed with secondary preventive intent, however will probably lead to a reduction of fracture rates markedly below 10%. A set of risk factors that allows identification of a high risk group that may benefit from bone density measurement and subsequent therapy to a relevant extent remains to be developed. Primary preventive strategies do not require bone density measurements.

   14.    Koyama, K., Ito, M., & Kotanagi, H. (2000). [Improvement of the efficiency of the treatment of gastric cancer by the standardization of the treatment plan]. Gan To Kagaku Ryoho, 27(9), 1375-9.
Abstract: Standardized treatment plan for gastric cancer was established in our department by which surgeons and nurses understood the treatment schedules of each gastric cancer patient as the common knowledge, and the cooperation of surgeons and nurses could be improved. Furthermore, the modality decreased the length of hospital stay from 35 +/- 15 days to 24 +/- 8 days, which indicated that the number of patients per one bed for one year increased from 10 to 15, and the efficiency of the treatment of gastric cancer patients 50% by our system.

   15.    Garfield, E. (2000 August).

   16.    Gadacz, T. R. (2000). Update on laparoscopic cholecystectomy, including a clinical pathway. Surg Clin North Am, 80(4), 1127-49.
Abstract: Laparoscopic cholecystectomy is a minimally invasive procedure in which the gallbladder is removed. Patients with symptomatic gallstones or biliary dyskinesis are eligible for this procedure. No specific contraindications exist except for poor surgical risk factors. The rate of conversion to an open technique is increased in patients with acute disease, pancreatitis, bleeding disorders, unusual anatomy, and prior upper abdominal surgery. Complications occur even with experienced laparoscopists, and the important technical aspects of surgery have been identified. The length of the hospital stay and postoperative recovery time is markedly shortened compared with that of standard cholecystectomy. This procedure offers sufficient advantages to patients that it has become the standard of practice in most cases.

   17.    Cohen, J., Stock, M., Chan, B., Meininger, M., Wax, M., Andersen, P., & Everts, E. (2000). Microvascular reconstruction and tracheotomy are significant determinants of resource utilization in head and neck surgery. Arch Otolaryngol Head Neck Surg, 126(8), 947-9.
Abstract: BACKGROUND: Successful "critical pathway" design and implementation are dependent on appropriate patient stratification according to those factors that are primary determinants of resource utilization. OBJECTIVES: To test the validity of our previously reported critical pathway design and to determine whether tracheotomy and microvascular reconstruction (MR) are primary determinants of resource utilization. DESIGN: Cost-effectiveness analysis. SETTING: Tertiary referral academic institution. METHODS: Retrospective analysis of data from 133 head and neck surgery cases in which the treatment regimen was based on critical pathways over a 26-month period. OUTCOME MEASURES: Length of stay and total patient charges were used as indices of resource utilization. One-way analysis of variance and t tests were used for statistical analysis of significance. RESULTS: Ninety patients (67.7%) underwent MR; 43 (32. 3%) did not. Seventy-five patients (56.4%) underwent tracheotomy; 58 (43.6%) did not. Four patient groups were constructed in decreasing order of complexity as follows: group 1, patients who underwent both tracheotomy and MR (n = 58); group 2, patients who underwent MR alone (n = 32); group 3, patients who underwent tracheotomy alone (n = 17); and group 4, patients who did not undergo either procedure (n = 26). Both tracheotomy and MR were found to be independent determinants of resource utilization and were additive when both were present. The length of stay varied from 8.4 days (in patients who underwent both procedures) to 6.7 days (in patients who did not undergo either procedure), with intermediate values in cases in which only 1 procedure was performed. The total charges varied in a similar manner from a high of $33,371 to a low of $19,994. Subanalysis with respect to intensive care unit, ward, and operating room charges showed a similar stratification. CONCLUSION: Tracheotomy and MR are both significant determinants of charges and length of stay in head and neck surgery cases and must be considered in the design of strategies to promote efficient resource utilization.

   18.    Vajkoczy, P., Menger, M. D., Goldbrunner, R., Ge, S., Fong, T. A., Vollmar, B., Schilling, L., Ullrich, A., Hirth, K. P., Tonn, J. C., Schmiedek, P., & Rempel, S. A. (2000). Targeting angiogenesis inhibits tumor infiltration and expression of the pro-invasive protein SPARC. Int J Cancer, 87(2), 261-8.
Abstract: The solid growth of high-grade glioma appears to be critically dependent on tumor angiogenesis. It remains unknown, however, whether the diffuse infiltration of glioma cells into healthy adjacent tissue is also dependent on the formation of new tumor vessels. Here, we analyze the relationship between tumor angiogenesis and tumor cell infiltration in an experimental glioma model. C6 cells were implanted into the dorsal skinfold chamber of nude mice, and tumor angiogenesis was monitored by intravital fluorescence videomicroscopy. Glioma infiltration was assessed by the extent of tumor cell invasion into the adjacent chamber tissue and by expression of SPARC, a cellular marker of glioma invasiveness. To test the hypothesis that glioma angiogenesis and glioma infiltration are codependent, we assessed tumor infiltration in both the presence and the absence of the angiogenesis inhibitor SU5416. SU5416 is a selective inhibitor of the VEGF/Flk-1 signal-transduction pathway, a critical pathway implicated in angiogenesis. Control tumors demonstrated both high angiogenic activity and tumor cell invasion accompanied by strong expression of SPARC in invading tumor cells at the tumor-host tissue border. SU5416-treated tumors demonstrated reduced vascular density and vascular surface in the tumor periphery accompanied by marked inhibition of glioma invasion and decreased SPARC expression. A direct effect of SU5416 on glioma cell motility and invasiveness was excluded by in vitro migration and invasion assays. These results suggest a crucial role for glioma-induced angiogenesis as a prerequisite for diffuse tumor invasion and a possible therapeutic role for anti-angiogenic compounds as inhibitors of both solid and diffuse infiltrative tumor growth. Copyright 2000 Wiley-Liss, Inc.

   19.    Wee, A. S., Cooper, W. B., Chatham, R. K., Cobb, A. B., & Murphy, T. (2000). The development of a stroke clinical pathway: an experience in a medium-sized community hospital. J Miss State Med Assoc, 41(7), 648-53.
Abstract: Patients with acute ischemic strokes were studied in a medium-sized community hospital in Mississippi. Studies were done before and after implementation of the stroke clinical care pathway with emphasis on the following clinical indicators: 1) performance of a brain CT scan, 2) the search for the etiology of the stroke, 3) whether the patient was treated emergently for hypertension, 4) the use of measures to prevent deep-vein thrombosis, and 5) prophylactic drug treatment against recurrent stroke after hospital discharge. Following application of the clinical pathway, there was a significant improvement in all the clinical indicators that were felt to require further attention and none had a setback. The length of hospital stay was decreased, and there was no significant increase in the hospital costs in the post-pathway study despite an increase in the number of diagnostic and therapeutic procedures performed. When applied properly, clinical pathways can effectively mobilize hospital resources, maximize quality of care, and at the same time minimize costs.

   20.    Philip, A. G., & Mills, P. C. (2000). Use of C-reactive protein in minimizing antibiotic exposure: experience with infants initially admitted to a well-baby nursery. Pediatrics, 106(1), E4.
Abstract: OBJECTIVE: To evaluate the use of a clinical pathway for neonatal sepsis in decisions about initiating and continuing antibiotic treatment. SETTING: A district hospital primarily served by private pediatricians practicing in a managed care environment. PATIENTS AND LABORATORY TESTS: All infants admitted to the well-baby nursery in 1997-1998 were eligible for this study. Infants born with a variety of risk factors (eg, borderline prematurity, membranes ruptured for over 18 hours, mother positive for group B streptococcus [GBS], and maternal fever) or clinical manifestations suggesting possible infection (either clinical signs or persistent hypoglycemia) were evaluated with white blood cell count, differential, and C-reactive protein (CRP) soon after birth and 12 hours later. Decisions to transfer to the neonatal intensive care unit and to treat with antibiotics were based on abnormal laboratory test results, particularly an increased level of CRP (>1 mg/dL), persistent hypoglycemia, or clinical signs. Discontinuation of antibiotic treatment was primarily based on return to normal of the CRP. RESULTS: Of 8299 live births, 7562 initially went to the well-baby nursery. Evaluation occurred in 1894 (25%) and 425 were transferred to the neonatal intensive care unit. In 162, antibiotics were discontinued within 48 hours. The majority were treated for 3 to 5 days, with only 19 (3 with GBS sepsis) treated for 6 days or more. There were 216 infants transferred because of risk factors and 209 because of clinical findings. Peak CRP primarily determined the duration of antibiotic treatment, with the mean peak CRP rising from 2.8 mg/dL in those treated for 3 days, to 3.8, 4.3, 8.4, 8.9, and 13. 7 mg/dL in those treated for 4, 5, 6, 7, or >7 days, respectively. The mean duration of treatment was 3.1 days. No infant initially treated with antibiotics and discharged when the CRP returned to normal was readmitted within the next month. No infant with normal values on the sepsis screen was readmitted within 1 month with evidence of bacterial infection, but 1 infant with no risk factors was readmitted at 22 days of age with GBS sepsis and meningitis. CONCLUSIONS: Using a clinical pathway for neonatal sepsis, which is based primarily on CRP determinations, can minimize antibiotic exposure and shorten hospital stays.

   21.    Kirsh, E. J., Worwag, E. M., Sinner, M., & Chodak, G. W. (2000). Using outcome data and patient satisfaction surveys to develop policies regarding minimum length of hospitalization after radical prostatectomy. Urology, 56(1), 101-6; discussion 106-7.
Abstract: OBJECTIVES: Changes in health care economics have prompted new clinical pathways for radical prostatectomy to reduce length of hospitalization after surgery to 1 day. We evaluated satisfaction, outcomes, and short-term morbidity in 187 consecutive patients with overnight hospitalization after radical retropubic prostatectomy (RRP). METHODS: In 1995, we initiated a critical pathway for RRP that included epidural anesthesia with or without spinal anesthesia and postoperative methadone, acetaminophen, and ibuprofen for pain control. Patients were discharged when they were afebrile, tolerating a regular diet, ambulating without assistance, and using oral medications for analgesia. An 18-item satisfaction survey was mailed to each patient 3 weeks after discharge. Responses to the postoperative survey, morbidity, blood loss, and use of transfusions were recorded. RESULTS: Of 252 patients who underwent RRP, 187 (74. 2%) were discharged 1 day after surgery. The mean age of patients was 61.4 years (range 42 to 73). A pelvic lymphadenectomy was performed in addition to the RRP in 32 men (17%). Epidural anesthesia with or without spinal anesthesia was used for all but 3 patients. The mean estimated blood loss was 1166 mL, and 24 patients (12.8%) required transfusion, with a mean of 1.9 U (range 1 to 6) of packed red blood cells. The postoperative complication rate was 11. 8%, of which 2.1% (n = 4) were definitely or probably related to our protocol. These complications included clot retention (n = 2), gastrointestinal bleeding (n = 1), and spinal headache (n = 1). Three of 187 patients were readmitted to the hospital within 30 days but only one (0.5%) required admission because of our protocol. The survey response rate was 91.4%. No patient was dissatisfied with his overall care, and only 10.5% of patients would have preferred to stay in the hospital longer. CONCLUSIONS: One-day hospitalization after RRP is associated with minimal postoperative morbidity and high patient satisfaction. Similar data are needed for RRP from other centers before policy decisions regarding the length of stay after this procedure are made.

   22.    Kelly, R. E. Jr, Wenger, A., Horton, C. Jr, Nuss, D., Croitoru, D. P., & Pestian, J. P. (2000). The effects of a pediatric unilateral inguinal hernia clinical pathway on quality and cost. J Pediatr Surg, 35(7), 1045-8.
Abstract: BACKGROUND/PURPOSE: The purpose of this study is to discover whether a pediatric inguinal hernia surgical clinical pathway (CP) reduces the frequency of wound infections, return visits, times associated with surgical repair, or costs. METHODS: A multidisciplinary team developed the inguinal hernia surgical clinical pathway. Healthy children greater than 50 weeks gestational age who required unilateral hernia repair were considered for the study. Two groups were formed: (1) an intervention group selected randomly (n = 46, CI = 95%, power = .80) from patients enrolled from November 1996 through April 1997, and (2) a retrospective cohort control group (n = 46) matched to each intervention patient by age, gender, and medical history. Analysis of variance and chi2 testing were used to test for significant differences between the 2 groups in postoperative wound infections, readmission and emergency department return visits within 72 hours, times associated with surgical repair, and costs. RESULTS: There were no significant differences in postoperative wound infections, times associated with surgical repair, or readmission rates within 72 hours. Total cost significantly decreased, by 10% (P< or = .05), for pathway patients ($982 v $880). CONCLUSION: These results show that the use of a pediatric inguinal hernia surgical clinical pathway is associated with reduced cost while maintaining quality of care.

   23.    Chu, S., & Cesnik, B. (2000). A three-tier clinical information systems design model. Int J Med Inf, 57(2-3), 91-107.
Abstract: Modern health care institutions are often multi-site organisations that implement heterogeneous information management systems interacting with distributed databases. Advances in treatment modality/technology and rapidly changing information technology create increasing demand for changes/redevelopment of many health information applications. These features spawn the need for solutions to (a) guarantee data exchange across different types of applications and database management systems, and (b) reduce the costs of systems development and modification. This paper explores the concept of 'middleware services' as a solution to achieve these goals. It reports on the successful application of a component-based 3-tier system architecture to develop a computerised clinical pathways management system. The implementation experience confirms a number of significant benefits of the 3-tier structure including, reusability, flexibility, significant reduction in costs and efforts of systems development, and provision of easy, open migration pathway for future change of technology and system redevelopment.

   24.    Burns, S. M., Ryan, B., & Burns, J. E. (2000). The weaning continuum use of Acute Physiology and Chronic Health Evaluation III, Burns Wean Assessment Program, Therapeutic Intervention Scoring System, and Wean Index scores to establish stages of weaning. Crit Care Med, 28(7), 2259-67.
Abstract: OBJECTIVE: To determine whether four stages of weaning (acute, prewean, wean, and outcome) could be identified by using clinical instruments designed to quantify severity of illness, patient stability, or weaning readiness. The instruments used were the Acute Physiology and Chronic Health Evaluation (APACHE III), the Therapeutic Intervention Scoring System (TISS), the Burns Wean Assessment Program (BWAP), and the Wean Index (WI). The stages were adapted from those proposed by the American Association of Critical Care Nurses Third National Study Group's Weaning Continuum Model. DESIGN: Prospective, convenience cohort. This study was part of a larger study designed to test an outcomes managed approach to weaning by using an outcomes manager and a clinical pathway. SETTING: University medical intensive care unit. PATIENTS: Adult patients requiring mechanical ventilation >3 days admitted to the medical intensive care unit between November 1994 and May 1995. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Scores for the APACHE III, TISS, BWAP, and WI were collected on 97 patients every other day until they weaned, were transferred, or died. Outcomes described for each stage of weaning were dated on the clinical pathway when achieved. Comments about patient stability and ventilator progress also were recorded along with a subjective determination of the stage of weaning. We used decision rules to identify time intervals for each stage of weaning and outcomes attained by stage. Finally, APACHE III, TISS, BWAP, and WI scores were placed in each stage by date for analysis. The APACHE III, TISS, and BWAP scores were able to differentiate the acute, prewean, and wean stages but not the outcome stage. CONCLUSIONS: By identifying distinct scores for each stage, we may be able to better explore appropriate interventions for the stages as well as predict weaning outcomes. Indices that include physiologic and respiratory factors can differentiate weaning stages, but respiratory factors alone cannot.

   25.    Basse, L., Hjort Jakobsen, D., Billesbolle, P., Werner, M., & Kehlet, H. (2000). A clinical pathway to accelerate recovery after colonic resection. Ann Surg, 232(1), 51-7.
Abstract: OBJECTIVE: To investigate the feasibility of a 48-hour postoperative stay program after colonic resection. SUMMARY BACKGROUND DATA: Postoperative hospital stay after colonic resection is usually 6 to 12 days, with a complication rate of 10% to 20%. Limiting factors for early recovery include stress-induced organ dysfunction, paralytic ileus, pain, and fatigue. It has been hypothesized that an accelerated multimodal rehabilitation program with optimal pain relief, stress reduction with regional anesthesia, early enteral nutrition, and early mobilization may enhance recovery and reduce the complication rate. METHODS: Sixty consecutive patients undergoing elective colonic resection were prospectively studied using a well-defined postoperative care program including continuous thoracic epidural analgesia and enforced early mobilization and enteral nutrition, and a planned 48-hour postoperative hospital stay. Postoperative follow-up was scheduled at 8 and 30 days. RESULTS: Median age was 74 years, with 20 patients in ASA group III-IV. Normal gastrointestinal function (defecation) occurred within 48 hours in 57 patients, and the median hospital stay was 2 days, with 32 patients staying 2 days after surgery. There were no cardiopulmonary complications. The readmission rate was 15%, including two patients with anastomotic dehiscence (one treated conservatively, one with colostomy); other readmissions required only short-term observation. CONCLUSION: A multimodal rehabilitation program may significantly reduce the postoperative hospital stay in high-risk patients undergoing colonic resection. Such a program may also reduce postoperative ileus and cardiopulmonary complications. These results may have important implications for the care of patients after colonic surgery and in the future assessment of open versus laparoscopic colonic resection.

   26.    Wiesel, S. W. (2000). 1999 International Society for the Study of the Lumbar Spine Presidential Address: education and quality care: our other missions.  Spine, 25(12), 1468-70.

   27.    Anonymous. (2000). The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Critical pathway for the treatment of established intracranial hypertension. Journal of Neurotrauma, 17(6-7), 537-8.
Notes: NO-AUTHOR INDICATOR: A

   28.    Vucic, N., Lang, N., Balic, S., Pilas, V., Anic, T., Nadinic, V., & Brborovic, O. (2000). Comparison between critical pathway guidelines and management of deep-vein thrombosis: retrospective cohort study. Croat Med J, 41(2), 163-7.
Abstract: AIM: To compare the key steps of standard deep-vein thrombosis management with the critical pathway practice guidelines, and to assess the outcome of the treatment after 6 months. METHOD: This retrospective cohort study (from January 1, 1997 to December 31, 1998) included 172 patients with uncomplicated deep-vein thrombosis of lower extremities, consecutively admitted via emergency room. The data were collected from the entry register in emergency room and medical charts. The outcome of therapy was assessed 6 months after the acute event. RESULTS: A bolus dose of heparin was administered to 81 (46%) patients. The recommended initial heparin infusion rate at 1250 U/h was employed in only 26 (15%) patients. Time to activated partial thromboplastin time >60 s was met in 29 (17%) patients. All patients but one received heparin therapy longer than 96 h. The recommended time to a therapeutic international normalized ratio of less than 120 h was achieved in 134 (78%) patients, but the average length of a stay in the hospital exceeded the recommended 5. 5 days by 86%. Six months later, compressive ultrasonography revealed 44 (28.9%) cases of complete vein obstruction, 67 (44.1%) cases of partial recanalization and 41 (27%) cases with a normal finding. Recurrent thrombosis developed in 16 patients (10.5%) and acute pulmonary embolism in 4 (2.6%) patients. CONCLUSION: Our results considerably differ from the critical pathway guidelines due to the lower initial heparin doses and longer diagnostic assessment of thrombosis etiology. Our approach to deep-vein thrombosis treatment was a combination of the critical pathway guidelines and the conventional regimen. The clinical outcome in our series did not differ significantly from the outcome after the conventional way of treatment.

   29.    Thomson, P., Angus, N. J., & Scott, J. (2000). Building a framework for getting evidence into critical care education and practice. Intensive Crit Care Nurs, 16(3), 164-174.
Abstract: One challenge for nurse educators is how best to enhance the integration of theory and practice elements in relation to critical care nursing. Practice should be evidence-based, i.e. the best available empirical evidence, including recent research findings, should be applied in practice in order to aid clinical decision-making. Barriers to the implementation of research exist at many levels including the individual practitioner, the clinical team, the practice setting and wider organizational factors. The authors propose that clinical guidelines can provide a vital link between theory and practice. At varying levels the use of care protocols, clinical pathways and algorithmic guidelines (provided they are rigorously reviewed and evidence-based) can help infuse research into practice, thereby promoting quality and standardization of care. The purpose of this paper is to discuss the value and use of these frameworks in promoting and raising awareness of the need for and use of evidence-based approaches to critical care education and practice. In this paper, we present outline information relating to an assessment method, adopted for continuing education courses in critical care within our department. This approach is designed to combine the best available evidence with reflective practice through the assessment process. (c) 2000 Harcourt Publishers Ltd Copyright 2000 Harcourt Publishers Ltd.

   30.    Ratcliffe, M. B., Khan, J. H., Magee, K. M., McElhinney, D. B., & Hubner, C. (2000). Collection of process data after cardiac surgery: initial implementation with a Java-based intranet applet. Ann Thorac Surg, 69(6), 1817-21; discussion 1821-2.
Abstract: BACKGROUND: Using a Java-based intranet program (applet), we collected postoperative process data after coronary artery bypass grafting. METHODS: A Java-based applet was developed and deployed on a hospital intranet. Briefly, the nurse entered patient process data using a point and click interface. The applet generated a nursing note, and process data were saved in a Microsoft Access database. In 10 patients, this method was validated by comparison with a retrospective chart review. In 45 consecutive patients, weekly control charts were generated from the data. When aberrations from the pathway occurred, feedback was initiated to restore the goals of the critical pathway. RESULTS: The intranet process data collection method was verified by a manual chart review with 98% sensitivity. The control charts for time to extubation, intensive care unit stay, and hospital stay showed a deviation from critical pathway goals after the first 20 patients. Feedback modulation was associated with a return to critical pathway goals. CONCLUSIONS: Java-based applets are inexpensive and can collect accurate postoperative process data, identify critical pathway deviations, and allow timely feedback of process data.

   31.    Markey, D. W., McGowan, J., & Hanks, J. B. (2000). The effect of clinical pathway implementation on total hospital costs for thyroidectomy and parathyroidectomy patients. Am Surg, 66(6), 533-8; discussion 538-9.
Abstract: Clinical pathways have long been used to guide the delivery of patient care in varied practice settings. There is little information in the literature to document the effectiveness of pathway implementation in general surgical populations. This study reports the effect of clinical pathway implementation in two general surgical patient groups, thyroidectomy and parathyroidectomy. Clinical pathways were implemented to serve patients undergoing thyroidectomy and parathyroidectomy surgery. The effects of both clinical pathways on total hospital costs, length of hospitalization, variances, and outcomes were collected and evaluated from July 1998 through July 1999. These data were compared to data from the previous year. The average length of stay for parathyroidectomy patients decreased from 2.4 to 1.5 days (P = 0.26) for pathway patients as compared to prepathway patients. The average cost per case decreased from $5071 to $4291 (P = 0.50) for parathyroidectomy pathway versus prepathway patients. The average length of stay decrease for thyroidectomy patients was 1.4 to 1.2 (P = 0.16) for the pathway to prepathway comparison. The average cost per case decrease was minor at $4117 to $4111. Pharmacy costs and laboratory utilization were effectively reduced. Perioperative costs rose dramatically during this period, operating room/central sterile supply cost per case rose 12 per cent, anesthesia supply cost per case rose 15 per cent, and surgical pathology costs increased 110 per cent overall for both patient groups. Clinical pathway implementation has allowed us to reduce or maintain total hospital costs in the face of rising perioperative costs. We conclude that implementation of these clinical pathways has allowed us to improve consistency with which we deliver care while maintaining the quality of patient outcomes and reducing the costs of care and length of hospital stay.

   32.    Klenner, S. (2000). Mapping out a clinical pathway. RN, 63(6), 33-36.
Abstract: When our small community hospital wanted to improve care, research led us to develop a clinical pathway -- with a twist -- to do the job.

   33.    Horner, G. H. (2000). Mapping the road to quality collaborative patient care in a behavioral health community treatment center. Avoiding the detours of managed care. Psychiatr Clin North Am, 23(2), 363-82.
Abstract: At this writing, the system and tools described have improved the author's organization's ability to meet managed care requirements better and support a collaborative care and case management model. Refer to the boxed information for the key functions and outcomes of the system. The Behavioral Health Multiaxial Protocol CareMapping System offers one approach to addressing the dilemma of health environmental change, managed care requirements, and financial constraints that have the potential to endanger the quality of clinical practice and to have a negative effect on patient and family outcomes. The tools illustrated in this article are in a constant cycle of revision and improvement and requires adequate clerical support to accomodate revision and tool improvement. Many more improvement initiatives are needed to improve the patient care process and organizational performance continuously. Because quality is a journey, the author hopes that her institution is on the right road and carries the correct map.

   34.    Grossman, M. D., & Born, C. (2000). Tertiary survey of the trauma patient in the intensive care unit. Surg Clin North Am, 80(3), 805-24.
Abstract: The issues surrounding the arrival of trauma patients to the ICU have been defined. By necessity, many of these topics are dealt with elsewhere in greater detail. The basic framework within which this phase of care could be optimized has been provided. Pitfalls related to patients' mode of arrival to the ICU affect subsequent management and should direct specific clinical activity. The tertiary survey is a complete summation and cataloguing of a patient's injuries. The need for ongoing resuscitation determines how much attention can be paid to the tertiary survey. Clinical suspicion based on mechanism and pattern of injury and thorough, repeated, complete physical examination are the essential elements of the tertiary survey. The survey is affected by factors that alter patients' mental status because examination is most reliable in patients who can localize pain. Medications, intoxication, and head injuries are common factors that interfere with the reliability of the tertiary survey for variable periods. Radiographic assessment is used to identify injuries suspected on the basis of mechanism of injury, injury pattern, and findings on physical examination. Some studies may be done portably; others require transport within the hospital. The intensivist must prioritize these ongoing diagnostic studies based on patient stability and the need for ongoing resuscitation.

   35.    Board, N., Brennan, N., & Caplan, G. A. (2000). A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients. Aust N Z J Public Health, 24(3), 305-11.
Abstract: OBJECTIVE: To test the cost effectiveness of Hospital in the Home compared to hospital admission for acute medical conditions. METHOD: Randomised controlled trial at the Prince of Wales Hospital, Sydney, from October 1995 to February, 1997; 100 patients with acute medical conditions admitted through the Emergency Department. RESULTS: The Hospital in the Home (HITH) group costs per separation ($1,764, CI 95% $1,416-$2,111, n = 50) were significantly lower (p < 0.0001, Mann-Whitney U-Wilcoxon Rank Sum) than the control group hospital separation ($3,614, CI 95% $2,881.37-$4,347.27, n = 47) with no significant difference in clinical outcomes, and comparable or better user satisfaction. CONCLUSION: Given the favourable clinical outcomes the HITH model produces at a lower cost, the cost-effectiveness of the care mode is high, and the allocative efficiency favourable. IMPLICATIONS: As a care model and critical pathway, HITH offers hospitals real bed day savings that can either be used to rationalise resource usage for a given level of activity, or increase throughput.

   36.    Feagan, B. G., Marrie, T. J., Lau, C. Y., Wheeler, S. L., Wong, C. J., & Vandervoort, M. K. (2000). A critical pathway for treatment of community-acquired pneumonia. JAMA, 283(20), 2654-5.

   37.    Burgess, D. S., & Lewis, J. S. 2nd. (2000). A critical pathway for treatment of community-acquired pneumonia [letter]. JAMA, 283(20), 2654-5.

   38.    Holloway, R. G., Benesch, C., & Rush, S. R. (2000). Stroke prevention: narrowing the evidence-practice gap. Neurology, 54(10), 1899-906.
Abstract: Many interventions reduce stroke risk. However, the full benefits of these interventions are not realized at current levels of utilization, as nearly all evidence-based or guideline-endorsed stroke prevention services are underused. The cause for such underuse is multifactorial and includes factors relating to both patients and providers, as well as to a health care system that has de-emphasized prevention at the expense of acute, technologically based care. Much like the evidence for stroke interventions themselves, there is a growing literature to support methods of implementing research evidence into clinical practice. There is still much to learn, however, about the effectiveness of interventions aimed at achieving changes in stroke prevention practice or the delivery of stroke prevention care. Nevertheless, there are many opportunities for providers, managed care organizations, and government to close the evidence-practice gap that exists for stroke prevention services. These opportunities exist in both the inpatient and outpatient setting, and depend on the neurologist taking a leading role in emphasizing the critical importance of risk factor identification and modification in all patients at risk for stroke. [References: 56]

   39.    Bayliss, V., Cherry, M., Locke, R., & Salter, L. (2000). Continence. Pathways for continence care: background and audit. British Journal of Nursing, 9(9), 590, 592, 594 passim.
Abstract: This article is the first in a series of three covering the use of care pathways for continence care. Trusts in Basingstoke, Swindon and Salisbury have collaborated in supporting their continence advisers in moving from finance-driven assessment data to evidence-based care pathways and the provision of patient information. This article identifies the background and approach to care pathways and addresses the quality issues. It details the issues facing continence advisers and how care pathways may help to address them. Furthermore, it describes a baseline audit which was carried out to ensure that facts rather than beliefs were being used and this demonstrated that little advice or treatment was actually reaching the patient.   (13 ref)

   40.    Cherry, M. (2000). Care pathways for urinary continence problems. Nursing Times, 96(19 NTplus), 7-8, 10.
Abstract: Maggie Cherry describes a joint project to develop care pathways for patients with urinary continence problems.   (1 ref)

   41.    Hilton, J. (2000). Learning curve. A care pathway for home parenteral nutrition. Nursing Times, 96(18), 38-9.
Abstract: Jenny Hilton, an independent nurse practitioner in Yeovil, Somerset, describes the development of an integrated care pathway for patients receiving home parenteral nutrition.   (4 ref)

   42.    Swanson, C. E., Yelland, C. E., & Day, G. A. (2000). Clinical pathways and fractured neck of femur [editorial; comment]. Med J Aust, 172(9), 415-6.
Notes: COMMENTS: Comment on: Med J Aust 2000 May 1;172(9):423-6

   43.    Choong, P. F., Langford, A. K., Dowsey, M. M., & Santamaria, N. M. (2000). Clinical pathway for fractured neck of femur: a prospective, controlled study [see comments]. Medical Journal of Australia, 172(9), 423-6.
Notes: COMMENTS: Comment in: Med J Aust 2000 May 1;172(9):415-6
Abstract: OBJECTIVE: To assess outcomes of using a clinical pathway for managing patients with fractured neck of femur. DESIGN: Prospective, pseudorandomised, controlled trial. SETTING: St Vincent's Hospital, Melbourne, Victoria (a tertiary referral, university teaching hospital), 1 October 1997 to 30 November 1998. PARTICIPANTS: 111 patients (80 women and 31 men; mean age, 81 years) admitted via the emergency department with a primary diagnosis of fractured neck of femur. INTERVENTIONS: Management guided by a clinical pathway (55 patients) or established standard of care (control group, 56 patients). MAIN OUTCOME MEASURES: Timing of referrals and discharge planning; total length of stay; and complication and readmission rates within 28 days of discharge. RESULTS: Patients managed according to the clinical pathway had a shorter total stay (6.6 versus 8.0 days; P = 0.03), even if assessment for placement by the Aged Care Assessment Service was required (9.5 versus 13.6 days; P = 0.03). There were no significant differences in complication and readmission rates between pathway and control patients (complication rates, 24% versus 36%; P = 0.40; readmission rates, 4% versus 11%; P = 0.28). CONCLUSION: Coordinated multidisciplinary care of patients with fractured neck of femur reduces length of stay without increasing complications.

   44.    O'neill, E. S., & Dluhy, N. M. (2000). Utility of structured care approaches in education and clinical practice. Nurs Outlook, 48(3), 132-5.

   45.    Holmboe, E. S., Meehan, T. P., Radford, M. J., Wang, Y., & Krumholz, H. M. (2000). What's happening in quality improvement at the local hospital: a state-wide study from the Cooperative Cardiovascular Project. Am J Med Qual, 15(3), 106-13.
Abstract: The objective of this study was to investigate what happened to improve the quality of care for acute myocardial infarction (AMI) at all 32 nonfederal hospitals in Connecticut and to assess the impact of the Cooperative Cardiovascular Project (CCP) on quality improvement (QI) activities for AMI. We performed a questionnaire study with secondary analyses using the CCP database. On-site interviews were conducted with QI directors at all 32 Connecticut nonfederal hospitals that participated in the Health Care Financing Administration's Cooperative Cardiovascular Project (CCP) in 1992-93 and 1995. The interviews sought information about the makeup of QI departments, specific approaches used to improve the care of patients with AMI, and the perceived value of the CCP to each individual hospital. Results showed that the number of full-time equivalents (FTEs) and FTEs per beds employed in QI departments ranged from 1 to 30 and from 0.4 to 7.9, respectively, with a registered nurse most often serving as the department head (27/32). Over half of the departments (17/32) had additional responsibilities. The majority (25/32) used some combination of physician champions, multidisciplinary QI teams, standing orders, or critical pathways to effect change in AMI care. Finally, 26 of the 32 hospitals believed the CCP was valuable because it provided credible benchmark data, a catalyst for change, or a specific focus on processes of care needing improvement in AMI. Despite great variability in institutional resources, all 32 hospitals used a similar combination of QI approaches to effect change in AMI care. However, there is variable scientific evidence supporting these approaches. Externally sponsored projects such as the CCP appear to play a useful role for individual hospitals. Defining the optimal methods of QI is difficult given that hospitals are using complex combinations of nonstandardized improvement interventions.

   46.    Hays, B. J., Kaiser, K. L., McMahon, C. E., & Kaup, K. L. (2000). Public health nursing data. Building the knowledge base for high-risk prenatal clients. MCN, American Journal of Maternal Child Nursing, 25(3), 151-8.
Abstract: PURPOSE: To examine and compare referral reason, clinical pathway variance, and intensity of need for care for high-risk prenatal clients of public health nurses. DESIGN: A prospective, descriptive design was used for this pilot study. METHODS: Reasons for referral to the high-risk prenatal home visitation program, variances from a prenatal clinical pathway, and intensity of need for care scores obtained using the Community Health Intensity Rating Scale (CHIRS) were collected at 28 weeks and 38 weeks of gestation from the clinical records of 20 high-risk prenatal clients (age range 16-43 years) visited by five expert public health nurses in one midplains public health nursing department. RESULTS: Findings indicated that the three sources of clinical data provided congruent but not identical data, with each contributing elements needed to specify public health nurses interventions for high-risk prenatal clients. CLINICAL IMPLICATIONS: Collaborative clinical research studies such as this one are useful in advancing evidenced-based practice in clinical agencies. The congruence between the clinical path variance and the intensity of need for care scores reaffirms the importance of the domain of health behavior intervention as a major aspect of public health nurses practice.

   47.    Pearson, S., Moraw, I., & Maddern, G. J. (2000). Clinical pathway management of total knee arthroplasty: a retrospective comparative study. Australian & New Zealand Journal of Surgery, 70(5), 351-4.
Abstract: BACKGROUND: Clinical pathways facilitate the management of defined patient groups using interdisciplinary plans of care. The aim of the present study was to evaluate the effectiveness of a clinical pathway in improving a range of selected outcome measures in patients who have undergone total knee arthroplasty (TKA). METHODS: The present study was conducted at Queen Elizabeth Hospital, Adelaide. Using a retrospective comparative study design, 119 TKA patients who were managed on a clinical pathway from July 1997 to January 1998 (group 2) were compared with a retrospective group of 58 patients who underwent the same procedure from July 1996 to January 1997 (group 1) prior to the pathway's implementation. The following outcomes were measured: length of hospital stay; postoperative complications; readmissions and emergency service visits within 6 months of discharge; day of transfer to the convalescent unit; convalescent unit utilization and admission and discharge times. RESULTS: There was a significant reduction in the median length of stay in group 2 patients (9 vs 7 days; P < 0.0001). In addition there was a 66% increase in the proportion of patients in group 2 who were admitted on the day of surgery (P < 0.0001) and a 19.6% increase in the number of patients discharged within 8 postoperative days (P < 0.01). There were no significant differences between the groups with respect to the occurrence of postoperative complications. Although there was a trend toward a reduction in emergency service utilization and readmissions within 6 months of discharge for patients managed on the pathway, this was not significant. CONCLUSIONS: The development and implementation of a TKA clinical pathway resulted in a significant reduction in length of stay and improved streamlining of admission, discharge and transfer processes without adversely affecting patient outcomes.

   48.    Kucenic, M. J., & Meyers, D. G. (2000). Impact of a clinical pathway on the care and costs of myocardial infarction. Angiology, 51(5), 393-404.
Abstract: A time series of 110 patients with acute myocardial infarction admitted between January 1992 and June 1997 examined the effects of a clinical pathway. The pathway reduced length of hospital stay by 2.2 days and hospital charges by $1,008 without compromising care quality and outcomes.

   49.    Konishi, T., & Agawa, S. (2000). [Clinical pathways in oncology]. Gan to Kagaku Ryoho [Japanese Journal of Cancer & Chemotherapy], 27(5), 655-70.
Abstract: The diagnosis-related-group/prospective-payment system (DRG/PPS) was introduced into the health care system of the United States in 1983. This system triggered the development and implementation of clinical pathways aimed at reducing the length and cost of hospitalization. In Japan, trial use of a Japanese version of DRG/PPS was initiated in November 1998 in 10 hospitals under the control of the Ministry of Health and Welfare, and full-scale implementation of the system is expected in the near future. Clinical pathways, therefore, are a current focus of attention, mainly because of their success in enhancing management efficiency in the U.S. However, in actual clinical settings where clinical pathways are used, several Japanese health care providers have come to realize that they are also useful in improving staff coordination, patient satisfaction, and patient care, rather than simply reducing the length of hospital stay and cost of health care. The introduction of clinical pathways requires that treatment of the disease in question be defined and standardized. The implementation of pathways for the treatment of cancer, however, might prove difficult because of the high frequency of variation. In our experience, the main reason for the use of clinical pathways is not to reduce the number of variant cases but to provide high-quality care through the promotion of a team approach to treatment and enhanced patient care. Therefore, even if there were frequent variances following surgery for cancer, those occurring in accordance with the pathophysiological state of the patient would not interfere with management by clinical pathways. Clinical pathways are advantageous because they allow patients to know their treatment schedule; to prepare for hospitalization procedures; to have a better perspective on discharge; to reduce anxiety regarding hospital admission, even if it is the first time; to communicate better with doctors, nurses, and other medical care staff, leading to greater trust; and to improve their ability for self-management. These features are all important for the improvement of patient care. Furthermore, clinical pathways may lead to a situation in which the cost of hospitalization can be predicted prior to admission, enabling patients to compare differences between several hospitals. From our experience with gastric cancer, breast cancer, and esophageal cancer management, we consider clinical pathways to be of great benefit in helping to reform the current medical care system in regard to the management of cancer patients as well as patients with other diseases. [References: 22]

   50.    Kelly, C. S., Andersen, C. L., Pestian, J. P., Wenger, A. D., Finch, A. B., Strope, G. L., & Luckstead, E. F. (2000). Improved outcomes for hospitalized asthmatic children using a clinical pathway [see comments]. Annals of Allergy, Asthma, & Immunology, 84(5), 509-16.
Notes: Comments: Comment in: Ann Allergy Asthma Immunol 2000 May;84(5):473-4
Abstract: BACKGROUND: Although asthma clinical pathways are used with increasing frequency, few controlled studies have evaluated the clinical and cost effectiveness of these pathways. OBJECTIVE: To evaluate the effect of an inpatient asthma clinical pathway on cost and quality of care for children with asthma. METHODS: One hundred forty-nine children were treated for status asthmaticus using an asthma clinical pathway in a children's hospital between September and December 1997. Thirty-four of 149 children treated with the clinical pathway were randomly selected. A retrospective cohort control group of non-pathway patients (N = 34) was matched with each pathway patient by age, race, gender, co-morbidities, asthma severity score, ICU admission, and time of year admitted. Differences between the two groups in length of stay, total costs, readmission rate, inpatient management, and discharge medications were compared. RESULTS: Length of stay was significantly lower in the clinical pathway group compared with the control group (36 hours versus 71 hours, P < .001) and total costs decreased significantly ($1685 versus $2829, P < .001) as a result of the pathway. Asthmatic children on the clinical pathway were significantly more likely than the control group to complete asthma teaching while hospitalized (65% versus 18%, P < .001), to be discharged with a prescription for a controller medication (88% versus 53%, P < .01), and to have a peak flow meter (57% versus 23%, P < .05) and a spacer device (100% versus 71%, P < .001) for home use. CONCLUSION: Implementation of this inpatient clinical pathway led to a decrease in length of stay and a reduction in total cost while improving quality of care for hospitalized asthmatic children.

   51.    Jano, S., & Harlin, S. A. (2000). Designing a carotid endarterectomy critical pathway for your organization. Military Medicine, 165(5), 385-9.
Abstract: BACKGROUND: Carotid endarterectomy (CEA) is one of the top-five surgical diagnosis-related groups at Keesler Medical Center. The geometric mean length of stay for CEA during fiscal year (FY) 1996 was 5.84 days (N = 41), compared with 1.79 for a benchmark facility. OBJECTIVE: Create a critical pathway to standardize care, maintain/improve patient outcomes, reduce lengths of stay, and decrease costs. METHODS: A multidisciplinary team was formed to evaluate four patient-flow options. The team decided to discharge patients directly from the intensive care unit to meet both patient and staff needs. RESULTS: The geometric mean length of stay decreased to 1.70 days (N = 54) in FY 1998, compared with 2.42 days (N = 40) in FY 1997. The cost savings ws $5,841 per case, compared with $1,684 before creation of the pathway. This represents an annual savings of more than $224,000 and a 30% reduction in length of stay. CONCLUSIONS: The CEA pathway has standardized the care received by this group of patients. By decreasing variation, processes have become routine and more efficient.

   52.    Hyman, B. T., Strickland, D., & Rebeck, G. W. (2000). Role of the low-density lipoprotein receptor-related protein in beta-amyloid metabolism and Alzheimer disease. Archives of Neurology, 57(5), 646-50.
Abstract: Deposition of beta-amyloid (A beta), a metabolite of approximately 4 kd of the amyloid precursor protein, is a critical pathological feature in Alzheimer disease. We postulate that deposition reflects an imbalance of A beta synthesis and clearance. Several pathways that impact A beta converge on a single receptor molecule, the low-density lipoprotein receptor-related protein (LRP). This multifunctional receptor is the major neuronal receptor both for apolipoprotein E (apoE, protein; APOE, gene) and for alpha2-macroglobulin (alpha2M, protein; A2M, gene), and it mediates clearance of apoE/A beta and alpha2M/A beta complexes. The LRP also interacts with the amyloid precursor protein itself. In this review, we highlight data that support a role for LRP in A beta metabolism and hypothesize that LRP therefore plays a critical role in Alzheimer disease. [References: 84]

   53.    Delmore, B. A., Hansen, D., Mooney, K. A., Paplanus, L. M., & Sutton, P. R. (2000). Research brief. An anticoagulation pathway for quality management. Applied Nursing Research, 13(2), 105-10.

   54.    Delmore, B. A., Hansen, D., Mooney, K. A., Paplanus, L. M., & Sutton, P. R. (2000). An anticoagulation pathway for quality management. Appl Nurs Res, 13(2), 105-10.

   55.    Cereda, M., Foti, G., Marcora, B., Gili, M., Giacomini, M., Sparacino, M. E., & Pesenti, A. (2000). Pressure support ventilation in patients with acute lung injury [see comments]. Critical Care Medicine, 28(5), 1269-75.
Notes: Comments: Comment in: Crit Care Med 2000 May;28(5):1652-3
Abstract: OBJECTIVES: To assess the success rate of pressure support ventilation (PSV) in acute lung injury patients undergoing continuous positive pressure ventilation (CPPV), to study physiologic changes after the transition from CPPV to PSV, and to investigate differences between patients who succeed and patients who fail PSV according to predetermined criteria. DESIGN: Observational study. SETTING: General intensive care unit in a teaching hospital. SUBJECTS: We studied 48 patients having acute lung injury, as defined by a PaO2/F(IO2) <300 mm Hg and the presence of bilateral infiltrates on chest radiograph, and ventilated with CPPV. We included patients with PaO2 >80 mm Hg, at positive end-expiratory pressure of <15 cm H2O and with F(IO2) up to 1.0. INTERVENTIONS: After enrollment, PSV was instituted and patients were strictly monitored during the following 48 hrs. Subjects who met any of the predefined PSV failure criteria during this period were returned to CPPV (Group F). PSV was continued in the remaining patients (Group S). MEASUREMENTS AND MAIN RESULTS: Gas exchange, respiratory mechanics, and hemodynamics measurements were collected before switching from CPPV to PSV and were repeated at 24 hrs after beginning PSV, or immediately before return to CPPV in Group F patients. The physiologic deadspace volume to tidal volume ratio (V(D)/V(T)) was obtained by the Enghoff's equation from the measurement of the mixed expired CO2 fraction. PSV resulted in a significant PaCO2 decrease (49.2+/-10.9 mm Hg to 44.4+/-7.2 mm Hg) and significant increases in minute volume (V(E))(9.0+/-2.3 L/min to 12.0+/-4.0 L/min) and arterial blood pH (7.405+/-0.054 to 7.435+/-0.064), with stable oxygenation and hemodynamics. In patients who were hypercapnic (PaCO2 >50 mm Hg) during CPPV, the V(E) increase was higher than in normocapnic patients. In the latter patients, PaCO2 and pH did not change significantly going from CPPV to PSV. A total of 38 patients (79%) were allocated to Group S and the remaining 10 patients were included in Group F. In Group S, positive endexpiratory pressure of 9.4+/-2.9 cm H2O (range, 3-14 cm H2O) and a PSV level of 14.9+/-3.8 cm H2O (range, 9-22 cm H2O) were applied. In Group F, positive end-expiratory pressure of 8.9+/-3.1 cm H2O (range, 5-15 cm H2O) and a PSV level of 21.6+/-4.6 cm H2O (range, 16-31 cm H2O) were adopted. Compared with Group S, Group F had a longer duration of intubation (20.2+/-19.2 days vs. 9.2+/-13.5 days), a lower static compliance of the respiratory system (30.4+/-16.5 mL/cm H2O vs. 41.7+/-15.0 mL/cm H2O), and a higher V(D)/V(T) (0.70+/-0.09 vs. 0.52+/-0.10), but similar oxygenation and positive end-expiratory pressure. V(E) was higher in Group F during both CPPV and PSV. CONCLUSIONS: In a relatively high proportion of the investigated patients, PSV was successful. The institution of PSV led to no major changes in oxygenation or in hemodynamics. PSV was associated with increases in V(E) and respiratory frequency. In patients who had been hypercapnic during CPPV, PaCO2 decreased despite a compensated pH. Compared with PSV success patients, patients who failed PSV appeared to be sicker, as shown by the higher duration of respiratory support, increased ventilatory needs, and decreased respiratory system compliance, despite similar arterial oxygenation and positive end-expiratory pressure.

   56.    Baldwin, Z. K., Meyerson, S. L., Skelly, C. L., McKinsey, J. F., Bassiouny, H. S., MacDonald, R. L., Gewertz, B. L., & Schwartz, L. B. (2000). Estimating the contemporary in-hospital costs of carotid endarterectomy. Annals of Vascular Surgery, 14(3), 210-5.
Abstract: Carotid endarterectomy (CEA) is the treatment of choice for symptomatic carotid stenosis and selective asymptomatic lesions. Alternative approaches have recently been championed under the guise of increased efficacy and decreased cost. The purpose of this study was to determine the results and in-hospital costs of CEA in a university hospital in the modern era. A retrospective chart review was undertaken for all patients undergoing CEA between January 1995 and December 1997. This corresponded to the implementation of a clinical path and extended efforts toward cost reduction. Patients undergoing combined CEA and cardiopulmonary bypass were excluded (n = 3). Cost was analyzed by the hospital Office of Program Planning using TSI (Transition Systems, Inc.) software. Direct costs are related to the utilization of clinical resources and are therefore manageable by clinicians (bed, room, supplies, nursing staff, OR staff, radiology, pharmacy, etc.). Total costs additionally include administration and overhead costs not directly chargeable to patient accounts. The results of this study showed that CEA can be safely performed with brief hospital stays and reasonable hospital costs. Results of alternative interventions for the treatment of carotid stenosis should be compared to these contemporary data.

   57.    Anonymous. (2000). 10 minutes with... is this the right path?... Terri Schmidt, MD. Emergency Medical Services, 29(5), 126-127.

   58.    Heller, R. F. (2000). Mortality from cardiovascular disease is too high outside capital cities [editorial; comment]. Medical Journal of Australia, 172(8), 360-1.
Notes: Comments: Comment on: Med J Aust 2000 Apr 17;172(8):370-4

   59.    Chan, J. J., & Chan, J. E. (2000). Medicine for the millennium: the challenge of postmodernism. Medical Journal of Australia, 172(7), 332-4.
Abstract: As the new millennium dawns, Australian society is becoming more post-modern, whereas the medical system remains increasingly modernist in its outlook. In this article, we discuss the emerging prevalence of post-modernism and examine current medical education and practice strategies, such as evidence-based medicine, from a post-modern perspective. We argue that if medicine does not respond to the ideas of post-modernism, which challenges the concepts of truth and our ability to be objective, it may become increasingly irrelevant to the needs of a changing society.

   60.    Matz, R. (2000). Use of critical pathways to improve the care of patients with acute myocardial infarction [letter; comment]. American Journal of Medicine, 108(5), 433.
Notes: Comments: Comment on: Am J Med 1999 Oct;107(4):324-31, Comment on: Am J Med 1999 Oct;107(4):397-8

   61.    Yuksel, N., Ginther, S., Man, P., & Tsuyuki, R. T. (2000). Underuse of inhaled corticosteroids in adults with asthma. Pharmacotherapy, 20(4), 387-93.
Abstract: Despite strong evidence that inhaled corticosteroids are beneficial in treating asthma, a number of small studies suggest a use rate of only 34-56%. The primary objective of this study was to determine patterns of prescribing inhaled corticosteroids for high-risk patients with asthma. Secondary objectives were to assess patterns of practice with respect to other agents prescribed before and at hospital discharge, and to determine if an emergency room asthma care map at one of the study hospitals was being followed. We retrospectively reviewed charts of 1022 patients with an acute attack of asthma treated in the emergency rooms of the Royal Alexandra Hospital and University of Alberta Hospital from January 1, 1996, to March 31, 1997. A forward stepwise logistic regression analysis was performed with the dependent variable defined as whether or not the patient was using an inhaled or oral corticosteroid during the index visit, and the independent variable being all major demographic variables. Inhaled corticosteroids were prescribed for 460 patients (52.0%) at the index visit. Overall, antiinflammatory drugs were prescribed for 548 patients (62.1%). An asthma care map was followed for 107 (16.8%) patients treated at the Royal Alexandra Hospital at the index visit. Logistic regression analysis showed that women and patients with more than one emergency room visit most likely were to be using inhaled or inhaled plus oral corticosteroids at the index visit. Documentation of drug therapy at discharge was poor for 42% of patients; therefore, analysis of practice patterns in this group was not attempted. This study shows that inhaled corticosteroids were prescribed for only about one-half of patients with an acute asthma attack. Given this low use by high-risk patients, the need for programs designed to improve asthma therapy is evident.

   62.    Wells, M. (2000). The role of the nurse in urinary incontinence. Baillieres Best Pract Res Clin Obstet Gynaecol, 14(2), 335-54.
Abstract: Specialist nursing is dynamic and needs to be sensitive, flexible and responsive to changes in care delivery. Clinical, educational, managerial, audit and research activities are all integral to the role of the specialist continence nurse. Nurse specialists need to be careful that they do not de-skill the role of more generalist nurses, but rather enhance their contribution to continence care. They also need to work collaboratively with their Specialist Continence Physiotherapist colleagues. There is evidence that care in the community setting and on ward areas is sub-optimal. Recent audit activities have shown that nurses feel comfortable about assessing the person with continence problems but less certain about treatment. One way to address this imbalance is through the use of care pathways, examples of which are illustrated.

   63.   Rosenstein, A. H. (2000). Measuring the benefits of clinical decision support: return on investment. Pharm Pract Manag Q, 20(1), 28-43.
Abstract: In an effort to provide high quality care in a more cost-effective manner, health care providers have found it necessary to implement a series of decision support strategies designed to improve outcomes of care. While each of these strategies has measurable benefits, they each come along with additional costs. This article will describe a methodology for measuring the costs and direct and indirect benefits from decision support activities.

   64.    Rogers, S. N., Naylor, R., Potter, L., & Magennis, P. (2000). Three years' experience of collaborative care pathways on a maxillofacial ward. Br J Oral Maxillofac Surg, 38(2), 132-7.
Abstract: Collaborative care pathways (CCPs) provide a framework for multidisciplinary patient care. They provide guidelines and a mechanism for audit, and were first introduced at the Regional Unit, Walton Hospital, Liverpool, in November 1994. They have been designed for many surgical groups. Between August 1996 and 31 July 1997, 955 patients were admitted on to the nine established pathways: fractured mandible (n=213), fractured zygoma (n=117), minor oral surgery (n=244), abscess (n=18), examination under anaesthesia (n=73), nasal surgery (n=73), osteotomy (n=80), salivary (n=63), and temporomandibular joint (n=74). The purpose of this article is to report the introduction of CCP in a maxillofacial ward and give results from a one-year audit. CCP have proved to be an extremely useful tool and have several advantages over traditional documentation. They are more accurate, easily computerized, and facilitate audit. They promote the development of guidelines and standardized perioperative care, and this in turn facilitates training and raises standards of care. Copyright 2000

   65.    Najib, M. M., Stein, G. E., & Goss, T. F. (2000). Cost-effectiveness of sparfloxacin compared with other oral antimicrobials in outpatient treatment of community-acquired pneumonia. Pharmacotherapy, 20(4), 461-9.
Abstract: We examined the cost-effectiveness of sparfloxacin compared with other selected oral antimicrobials in outpatient treatment of community-acquired pneumonia (CAP) using clinical pathway-based decision analysis. Cost estimates were obtained from medical claims databases and Medicare reimbursement schedules. Probability estimates were derived from published clinical trials, the medical literature, and clinical expert opinion. Overall adjusted efficacy rates were 89% for sparfloxacin, 79.4% for azithromycin, 77.8% for clarithromycin, 73% for cefaclor, 70.8% for amoxicillin-clavulanic acid, and 69% for erythromycin. The expected total cost/CAP episode of treatment with sparfloxacin was $216.07 compared with $258.97, $297.08, $345.75, $389.80, and $395.93 for azithromycin, clarithromycin, erythromycin, amoxicillin-clavulanic acid, and cefaclor, respectively. Therapy with sparfloxacin for managing CAP is cost effective-relative to other commonly prescribed antibiotics, resulting in net cost savings.

   66.    Kaplan, R. M. (2000). Two pathways to prevention. Am Psychol, 55(4), 382-96.
Abstract: Health promotion and disease prevention programs are becoming important components of contemporary health care. There are at least 2 pathways to the enhancement of population health status through disease prevention. The first pathway requires the early diagnosis and treatment of disease. The second pathway promotes healthy lifestyles and disregards the requirement that a condition must be diagnosed before intervention is recommended. Data from several evaluations suggest that prevention efforts that rely on diagnosis have produced somewhat limited benefits, whereas primary prevention efforts may have substantial benefits. Current health policy places greater emphasis on secondary prevention. The objectives of improved population health might be better achieved by devoting relatively more resources to primary prevention through the promotion of healthy behaviors.

   67.    Ganiats, T. G. (2000). What to do until the POEMs arrive. An endothelial example. Journal of Family Practice, 49(4), 362-8.
Abstract: There is a growing trend toward evidence-based medicine, in which patient-oriented data are valued more highly than disease-oriented evidence (DOEs). In the vernacular of evidence-based medicine, the old DOEs are slowly being replaced by POEMs (patient-oriented evidence that matters). Unfortunately, POEMs do not yet exist to meet every family-practice need. When there are no POEMs to determine an appropriate therapeutic choice, another decision-making method must be used. This method includes liberal use of DOEs combined with thoughtful use of causal pathways to provide preliminary direction. This article applies that method to an example from the growing basic science surrounding endothelial functioning.

   68.    Chou, P., Chen, C., & Lu, M. (2000). Application of nursing care map in caring for stroke patients at home [Chinese]. Nursing Research (China), 8(2), 249-59.
Abstract: The aim of the study was to utilize the "nursing care map" (NCM) for home care stroke patients. A longitudinal research model was used in this study. The sample consisted of 31 stroke patients and their caregivers. The findings of the study indicated: (1) 2.8% variance was found. Patient condition and family financial stress were major facfors for variance in employing NCM (92%). (2) Patient complications were improved significantly by applying the nursing care map (OR = 17, p < 0.001). Incidence of pressure sores was most significantly decreased. The caregivers' competence in caring were also significantly improved. (3) Families' average satisfaction toward the nursing care was 4.13 (M = 4, range 1-5) Significant factors influencing quality of home health care included: preexisting complications, caregiver's educational level and family income. In conclusion, the nursing care map could provide a suitable patient care model for home care stroke patients.   (8 ref)

   69.    Anonymous. (2000). CRITICAL PATH NETWORK. Care planning algorithm for lower extremity amputation. Hospital Case Management, 8(4), 55-58.

   70.    Anonymous. (2000). Care planning algorithm for lower-extremity amputation. Hospital Case Management, 8(4), 55-8.
Notes: NO-AUTHOR INDICATOR: A

   71.    Fisk, G. D., & Wyss, J. M. (2000). Descending projections of infralimbic cortex that mediate stimulation-evoked changes in arterial pressure. Brain Research, 859(1), 83-95.
Abstract: The infralimbic cortex (IL) of the rat can modify autonomic nervous system activity, but the critical pathway(s) that mediate this influence are unclear. To define the potential pathways, the first series of experiments characterizes the descending projections of IL and the neighboring cortical areas using Phaseolus vulgaris leucoagglutinin (PHA-L). IL has prominent projections to the central nucleus of the amygdala (Ce), the mediodorsal nucleus of the thalamus (MD), the lateral hypothalamic area (LHA), the periaqueductal gray (PAG), the parabrachial nucleus (Pb), and the nucleus of the solitary tract (NTS). The density and selectivity of these projections suggest that the LHA and the PAG mediate the ability of the IL to regulate cardiovascular function. The second series of experiments demonstrates that locally anesthetizing neurons in either the LHA or PAG with lidocaine attenuates the hypotensive effects produced by electrical stimulation of the IL. Similarly, microinjections of cobalt chloride (a neurotransmission blocker) into the anterior portion of the LHA also decrease the arterial pressure responses to IL stimulation, suggesting that the ability of lidocaine to reversibly block the evoked response is due to inactivation of neurons in the LHA. These data indicate that hypotension evoked by stimulation of IL is mediated, at least in part, by direct or indirect projections to the LHA and through the PAG.

   72.    Nott, A. (2000). Learning curve. The care pathway approach in an acute mental health inpatient unit. Nursing Times, 96(11), 44-5.
Abstract: A fresh approach to school nursing, where routine developmental screening is replaced by targeting health areas of special concern to secondary school pupils, has led to a successful bid for Health Action Zone funding for five school nurses in an area of high social deprivation. Carol Bowen, head of school nursing services and community nursing services manager at Tees and Forth East Yorkshire NHS trust, explains what the project hopes to achieve.   (4 ref)

   73.    Morris, A. H. (2000). Developing and implementing computerized protocols for standardization of clinical decisions. Annals of Internal Medicine, 132(5), 373-83.
Abstract: Humans have only a limited ability to incorporate information in decision making. In certain situations, the mismatch between this limitation and the availability of extensive information contributes to the varying performance and high error rate of clinical decision makers. Variation in clinical practice is due in part to clinicians' poor compliance with guidelines and recommended therapies. The use of decision-support tools is a response to both the information revolution and poor compliance. Computerized protocols used to deliver decision support can be configured to contain much more detail than textual guidelines or paper-based flow diagrams. Such protocols can generate patient-specific instructions for therapy that can be carried out with little interclinician variability; however, clinicians must be willing to modify personal styles of clinical management. Protocols need not be perfect. Several defensible and reasonable approaches are available for clinical problems. However, one of these reasonable approaches must be chosen and incorporated into the protocol to promote consistent clinical decisions. This reasoning is the basis of an explicit method of decision support that allows the rigorous evaluation of interventions, including use of the protocols themselves. Computerized protocols for mechanical ventilation and management of intravenous fluid and hemodynamic factors in patients with the acute respiratory distress syndrome provide case studies for this discussion.

   74.    McBride, K. E., & Rines, B. (2000). Sexuality and spinal cord injury: a road map for nurses. SCI Nurs, 17(1), 8-13.
Abstract: The focus of this article is to describe and outline a method of nursing care intervention that will assist nurses in addressing the sexual health concerns of their clients with spinal cord impairment (SCI). A "road map" is described that serves as a guide to recognize and respond to clients' sexual health concerns. A sexual assessment framework is explored to help nurses identify common concerns shared by persons with SCI. Each area will be defined, and the impact of SCI will be discussed. The PLISSIT Model is presented as a way for planning nursing interventions to address sexual health concerns. Strategies are identified for talking with clients about changes to sexuality and sexual function following SCI.

   75.    Adams, J. (2000). Spotlight on research... commentary on Husbands JM, Weber RS, Karpati RL et al (1999). Clinical care pathways: decreasing resource utilization in head and neck surgical patients. OTOLARYNGOLOGY-HEAD AND NECK SURGERY, 120(6), 755-759. ORL-Head & Neck Nursing, 18(2), 23.
Abstract: This article discusses the use of clinical pathways as a means of controlling resource utilization and standardization of resource utilization while maintaining positive patient outcomes. Clinical Care Pathways (CCPs) are defined as algorithms designated to achieve realistic goals for clinical progress through coordination of a multidisciplinary management team that simultaneously seeks to maximize efficient use of resources while maintaining acceptable standards of care.

   76.    Schurig, L. (2000). Exploring the cost of business. J Cardiovasc Manag, 11(2), 12-21.

   77.    Novalis, S. D., Messenger, M. F., & Morris, L. (2000). Occupational therapy benchmarks within orthopedic (hip) critical pathways. American Journal of Occupational Therapy, 54(2), 155-8.
Abstract: OBJECTIVE: This study examined patient performance benchmarks for occupational therapy within orthopedic (hip) critical pathways. METHOD: Eight orthopedic (hip) critical pathways gathered from occupational therapy practitioners working in hospital and rehabilitation settings were examined to determine commonalities and differences of occupational therapy benchmarks, disciplines involved, and identified allowable variances. A comparison and contrast matrix was developed to provide a visual means of reviewing the data. RESULTS: Nursing, physical therapy, and occupational therapy were disciplines consistently involved in the pathways. Activities of daily living related to self-care were the most consistently used occupational therapy benchmark within the sample pathways, and functional transfers were the second most-used benchmark. The remaining occupational therapy benchmarks varied, and little commonality was found in their use. Frequency of use also varied among the eight pathways. Five of eight pathways specifically coded variances, with the remaining three providing space for explanation of the variance. CONCLUSION: Although these eight orthopedic (hip) critical pathways included occupational therapy benchmarks, further development and definition of the role of occupational therapy within subsequent orthopedic (hip) critical pathways is needed.

   78.    Harkleroad, A., Schirf, D., Volpe, J., & Holm, M. B. (2000). Critical pathway development: an integrative literature review. American Journal of Occupational Therapy, 54(2), 148-54.
Abstract: OBJECTIVE: The purpose of this integrative literature review was to summarize and analyze the methods used to develop critical pathways. METHOD: Relevant articles published in occupational therapy, physical therapy, nursing, and medical journals between 1992 and 1997 were reviewed to extract various methods and the steps or criteria used for each method. RESULTS: Nine approaches to critical pathway development and the steps or criteria involved in each method are presented in tabular format. The most detailed approach was used as a gold standard, and the other approaches were compared to it. CONCLUSION: This review should assist occupational therapy practitioners working with various diagnostic populations to understand the methods used, and steps involved, in the development of critical pathways. It should also serve as a resource for practitioners who have the opportunity to participate in critical pathway development. [References: 12]

   79.    Blumenthal, C. (2000). Implementing clinical pathways in a small agency: surviving IPS and preparing for PPS. Home Healthcare Nurse Manager, 4(2), 19-25.
Abstract: A rural health department-based home health agency's financial status was jeopardized by the BBA's per-beneficiary and reduced per-visit cost limits. This article describes the process used and the benefits gained from reorganizing operations and traditional practice patterns. These strategies are helping position the agency for PPS later this year.   (9 ref)

   80.    Berry, V., Cranston, B., & Fox, T. (2000). Tips, tools, and techniques. Caremapping: "what's in it for nurses?". Lippincott's Case Management, 5(2), 63-72.

   81.    Berry, V., Cranston, B., & Fox, T. (2000). Caremapping: "what's in it for nurses"? Nurs Case Manag, 5(2), 63-72.

   82.    Zink, J., & Robertson, S. (2000). Clinical integration and nursing leadership across an integrated delivery system. Seminars for Nurse Managers, 8(1), 26-30.
Abstract: As new health systems struggle to combine in today's challenging health care market, mechanisms that facilitate and enhance integration become increasingly important. This article describes the use of clinical paths in an integrated delivery system (IDS) as a methodology to establish a single standard of high-quality care. Through education and sharing of staff development resources across the IDS, the system nurse executive at one large IDS promotes professional practice. As clinical paths are developed across the system, the best clinical practice is put to paper, providing a framework for outcome-driven care. The nurse manager assesses staff's use of clinical paths as an evaluation of their skills and competency and to identify new educational and growth opportunities. Copyright &#169; 2000 by W.B. Saunders Company   (5 ref)

   83.    O'Brien, C. J., Traynor, S. J., McNeil, E., McMahon, J. D., & Chaplin, J. M. (2000). The use of clinical criteria alone in the management of the clinically negative neck among patients with squamous cell carcinoma of the oral cavity and oropharynx. Archives of Otolaryngology -- Head & Neck Surgery, 126(3), 360-5.
Abstract: BACKGROUND: Management of the clinically negative neck among patients with oral and oropharyngeal squamous cell carcinoma at the Royal Prince Alfred Hospital, Sydney, Australia has been based on the site and stage of the primary cancer, the likely incidence of microscopic nodal involvement, the treatment modality used for the primary cancer, and whether the neck will be entered during resection or reconstruction. This report analyzes the results of treatment when patients are allocated to either treatment or observation of the neck based on these clinical factors. METHODS: This is a prospectively documented series of 162 consecutively treated patients with squamous cell carcinoma of the oral cavity and oropharynx and clinically negative necks, treated by 1 surgeon (C.J.O.). There were 128 oral cavity and 34 oropharyngeal cancers clinically staged at T1 for 62 patients, T2 for 61, T3 for 16, and T4 for 23 patients. Management of the neck consisted of elective neck dissection (END) in 96 patients (12 bilateral), elective radiotherapy in 8, and observation in 58. Neck treatment correlated with the T stage in a statistically significant way. Forty-six patients underwent postoperative radiotherapy, which was directed to the neck in 22 patients because of pathological findings following neck dissection. Free-flap reconstruction was used in 90 patients. RESULTS: Metastatic squamous cell carcinoma was identified in 32 of 108 neck dissections (30%). There was 1 positive node in 15 necks, 2 positive nodes in 11 necks, and 3 or more positive nodes in 6 necks. Extracapsular spread was present in 8 of 32 positive END specimens (25%). Regional control rates in the neck at 3 years were 94% for END, 100% for elective radiotherapy, and 98% for patients initially observed and then treated by therapeutic neck dissection. Death with uncontrolled disease in the neck occurred in 4 of 96 patients (4%) after END and 1 of 58 patients (2%) after neck observation. Overall disease-specific survival was 83%, comprising an 86% rate for patients with pathologically negative necks and 68% if pathologically positive. Disease-specific survival was 86% at 3 years for patients having END, 67% following radiotherapy, and 94% for the observation group. CONCLUSIONS: Elective neck dissection was performed in most patients, and occult metastatic disease was found in nearly 30% of neck dissections. Observation was most frequently used for patients with early stage disease, and subsequent development of neck metastases was uncommon (9%) in this group. Selective treatment of the clinically negative neck based on the primary tumor site and stage led to a high rate of regional disease control in this series.

   84.    Lucas, C. (2000). Linking patient learning across a diverse, scattered system. Strateg Healthc Excell, 13(3), 8-12.

   85.    Lewis, C. K. (2000). A performance improvement initiative: development of a peripheral vascular pathway. Journal of Vascular Nursing, 18(1), 13-21.
Abstract: Health care institutions today are being challenged to provide cost-effective, quality care. High-cost Diagnostic Related Groups are being targeted for performance improvement initiatives. A Peripheral Vascular Bypass Chartered Team was formed to review current practices and identify, opportunities for system improvements. Data analysis, the literature, and best practices were reviewed. Emphasis on the financial, clinical, and quality outcomes are discussed in relation to a clinical pathway and protocol development in an effort to better manage this population.   (12 ref)

   86.    Herbermann, M. (2000). Building a seamless system of hospital-home health services. Seminars for Nurse Managers, 8(1), 20-5.
Abstract: Robert Wood Johnson University Hospital is committed to expanding the continuum of care. To this end, 2 task forces were developed simultaneously. One was created to streamline the discharge transition planning process and produce a more efficient and effective system. The other focused specifically on the coronary artery bypass graft population, with the objective of reducing length of stay without compromising quality of care. This article describes the process from the perspective of the Home Care Department's involvement. Computerization, standardization of physician orders and nursing care plans, and testing patients' knowledge regarding nutrition and medications after discharge from the hospital are described in detail. Including home care in the planning process is the key to achieving a seamless continuum of care. Copyright (c) 2000 by W.B. Saunders Company   (5 ref)

   87.    DeMonaco, H. J. (2000). Guidelines, pathways, and the end result [editorial; comment]. Critical Care Medicine, 28(3), 889-90.
Notes: Comments: Comment on: Crit Care Med 2000 Mar;28(3):707-13

   88.    Dahl, J., & Penque, S. (2000). The effects of an advanced practice nurse-directed heart failure program. Nurse Practitioner, 25(3), 61-62, 65-66, 68 passim.
Abstract: A study was conducted to determine if an inpatient heart failure program directed by an advanced practice nurse (APN) affects the following patient outcomes: length of hospital stay, mortality, readmission rates, and adherence to the recommended clinical regimen. Evaluating APN-directed heart failure programs may assist hospitals and clinics to determine whether such programs should be replaced, modified, continued, or replicated. For those facilities that are considering beginning a heart failure program, the data provided in this study may help establish the necessity of developing such a program or provide ideas for program design. The APN has an integral role in program design and can assist in achieving positive patient outcomes.   (24 ref)

   89.    Chen, A. Y., Callender, D., Mansyur, C., Reyna, K. M., Limitone, E., & Goepfert, H. (2000). The impact of clinical pathways on the practice of head and neck oncologic surgery: the University of Texas M. D. Anderson Cancer Center Experience. Archives of Otolaryngology -- Head & Neck Surgery, 126 (3), 322-6.
Abstract: OBJECTIVE: To assess the impact of clinical pathways on the practice of head and neck oncologic surgery in an academic center. DESIGN: Cross-sectional study. SETTING: Cancer treatment center. PATIENTS: The study population consisted of 3 groups of patients who underwent unilateral neck dissection and were treated in the Department of Head and Neck Surgery of the University of Texas M. D. Anderson Cancer Center, Houston. Additional procedures which may have been performed were direct laryngoscopy, rigid esophagoscopy, and/or dental extractions. Ninety-six patients treated during 1993-1994 prior to the implementation of the clinical pathway (historical control group) were compared with 94 patients treated during 1996-1998, 64 who were not (contemporaneous nonpathway group) and 30 who were managed on the clinical pathway (pathway group). Patients from 1995 were excluded since the pathway was in the planning stages then. MAIN OUTCOME MEASURES: Median length of stay; median total costs of care. RESULTS: The median length of hospital stay of the historical control, contemporaneous nonpathway, and pathway groups decreased from 4.0 to 2.0 days (P<.001). The total median costs of care were less in the pathway group as compared with the historical control group ($6,227 and $8,459, respectively, P<.001) and also less in the contemporaneous nonpathway group compared with the historical control group (S6885 and $8,459, respectively, P<.001). Mean and median length of hospital stay and costs were lower in the pathway group as compared with the nonpathway group but not significantly (P = .11 and P = .07, respectively) The contemporaneous nonpathway and pathway groups did not differ in complications or readmissions. CONCLUSIONS: Development and implementation of this clinical pathway played a statistically significant role in decreasing length of hospital stay and total costs of care associated with neck dissection between nonpathway and pathway patients. Thus, a more cost-effective practice environment has resulted for all of our patients.

   90.    Carey, R. G. (2000). Measuring health care quality. How do you know your care has improved? Eval Health Prof, 23(1), 43-57.
Abstract: Statistical process control (SPC) was developed in the 1920s as a way of detecting defects in manufacturing processes. During the past decade, SPC has been adopted by service industries and is increasingly being employed by health care organizations. The methodology involves the construction of a control chart to detect variation within processes. Variation is neither good nor bad in itself; therefore, the impact of variation must be interpreted within the context of expected outcomes, acceptable limits, and the process itself. In this article, the concept of statistical process control is explained, and examples are provided to illustrate how SPC can be applied in a clinical setting.

   91.    Burdis, C. E. (2000). Integrated care pathways in acute care. Itin, 12(1), 10-2.

   92.   Anonymous. (2000). Periop pathway cuts costs, improves efficiency: fewer preference cards contribute to savings. Same-Day Surgery, 24(3), 34-36.

   93.    Anonymous. (2000). Managed care or not, staff work harder, faster. Hospital Case Management, 8(3), 35,48.

   94.    Anonymous. (2000). CRITICAL PATH NETWORK. Practice guideline tackles fall risk: Medical Directors' algorithm aids risk assessment... reprinted with permission of the American Medical Directors Association, Columbia, MD. Hospital Case Management, 8(3), 39-42.

   95.    Hillert, B., Remonte, S., Rodgers, G., Yancy, C. W., & Kaul, A. F. (2000). Improving patient outcomes by pooling resources (the Texas Heart Care Partnership experience). American Journal of Cardiology, 85(3A), 43A-51A.
Abstract: The morbidity and mortality associated with cardiovascular disease presents an enormous humanistic and economic burden in the United States. In Texas, cardiovascular disease has been the leading cause of death since 1950. Risk-factor modification has been targeted in the secondary prevention of cardiovascular disease, including lipid management, smoking cessation, improved control of blood pressure, physical activity, weight management, the use of antiplatelet agents/anticoagulants, angiotensin-converting enzyme (ACE) inhibitors in congestive heart failure, beta blockers after myocardial infarction, and estrogen replacement therapy. The Heart Care Partnership (HCP) is a multifaceted interactive program designed to improve risk-factor management in the secondary prevention of cardiovascular disease through physician education, participation, and consensus development in addition to practice improvement processes and patient education. Development and implementation of the Texas HCP was a joint effort of the Texas Medical Association, the Texas Affiliate of the American Heart Association, and Merck & Co. This program helps hospitals improve the quality of care and outcomes for patients with heart disease. Program resources include educational workshops, quality improvement processes, and patient educational materials. HCP workshops address the treatment gap, define optimal care, and help define institution-specific plans for treating heart disease. Quality-improvement processes provide hospitals with baseline data and tools to improve and measure outcomes over time. The HCP workshops are provided as a combination of lectures, interactive discussions, and small group planning sessions designed to encourage audience participation. Upon completing the HCP program, participants are able to (1) describe the evidence-based medicine supporting secondary prevention of cardiovascular disease; (2) identify and prioritize cardiovascular disease risk factors for secondary prevention; (3) identify barriers to and solutions for implementing secondary prevention; and (4) develop site-based plans for cardiovascular risk-factor modification with definite time lines for implementation ("care maps"). The HCP's initial audit of medical practices indicates that Texas appears to share the same deficiencies in the secondary prevention of cardiovascular disease as the rest of the country. However, improvements can be demonstrated in both the hospital and physician office settings through the HCP. The HCP facilitated the cooperation of the medical community in the state of Texas to work together in a synchronized, communicative manner to decrease coronary events. This partnership represents a watershed event in the history of Texas medicine. It is the first time that such a statewide team approach to address a public health issue has been initiated. In the past, medical organizations within the state have had disparate goals and multiple strategies for achieving them.

   96.    Marrie, T. J., Lau, C. Y., Wheeler, S. L., Wong, C. J., Vandervoort, M. K., & Feagan, B. G. (2000). A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin. JAMA, 283(6), 749-55.
Abstract: CONTEXT: Large variations exist among hospitals in the use of treatment resources for community-acquired pneumonia (CAP). Lack of a common approach to the diagnosis and treatment of CAP has been cited as an explanation for these variations. OBJECTIVE: To determine if use of a critical pathway improves the efficiency of treatment for CAP without compromising the well-being of patients. DESIGN: Multicenter controlled clinical trial with cluster randomization and up to 6 weeks of follow-up. SETTING: Nineteen teaching and community hospitals in Canada. PATIENTS: A total of 1743 patients with CAP presenting to the emergency department at 1 of the participating institutions between January 1 and July 31, 1998. INTERVENTION: Hospitals were assigned to continue conventional management (n = 10) or implement the critical pathway (n = 9), which consisted of a clinical prediction rule to guide the admission decision, levofloxacin therapy, and practice guidelines. MAIN OUTCOME MEASURES: Effectiveness of the critical pathway, as measured by health-related quality of life on the Short-Form 36 Physical Component Summary (SF-36 PCS) scale at 6 weeks; and resource utilization, as measured by the number of bed days per patient managed (BDPM). RESULTS: Quality of life and the occurrence of complications, readmission, and mortality were not different for the 2 strategies; the 1-sided 95% confidence limit of the between-group difference in the SF-36 PCS change score was 2.4 points, which was within a predefined 3-point boundary for equivalence. Pathway use was associated with a 1.7-day reduction in BDPM (4.4 vs 6.1 days; P = .04) and an 18% decrease in the admission of low-risk patients (31% vs 49%; P = .01). Although inpatients at critical pathway hospitals had more severe disease, they required 1.7 fewer days of intravenous therapy (4.6 vs 6.3 days; P = .01) and were more likely to receive treatment with a single class of antibiotic (64% vs 27%; P<.001). CONCLUSION: In this study, implementation of a critical pathway reduced the use of institutional resources without causing adverse effects on the well-being of patients.

   97.    Every, N. R., Hochman, J., Becker, R., Kopecky, S., & Cannon, C. P. (2000). Critical pathways : a review. Committee on Acute Cardiac Care, Council on Clinical Cardiology, American Heart Association. Circulation, 101 (4), 461-5.

   98.    Wild, L. R., & Hendricks, H. G. (2000). Speaking the same language: improving evaluation of patient-focused outcomes using standardized terminology. Topics in Health Information Management, 20(3), 35-43.

   99.    Warren, R. M., & Hayes, C. (2000). Localization of breast lesions shown only on MRI--a review for the UK Study of MRI Screening for Breast Cancer. Advisory Group of MARIBS. Br J Radiol, 73(866), 123-32.
Abstract: The UK study of screening for breast cancer compares mammography and dynamic contrast enhanced MRI of the breast in women at high genetic risk of developing cancer. Owing to the high sensitivity of MR in the breast, it is anticipated that some lesions will be visible only on MR. A key issue for the study is how to localize these lesions for histological verification and removal. This article reviews available methods and describes the current UK expertise and recent European developments. The use of MR compatible wires and markers has been explored in a phantom. The use of these markers in vivo is demonstrated in a case imaged by MR and mammography and further discussed. The susceptibility artefacts produced on MRI, and technical properties associated with these needles, wires and markers are discussed. The clinical pathway by which these lesions will be worked up for the study, and the quality control procedures for keeping the number of such biopsies to a minimum, are described. There is an urgent need for further centres in the UK to become proficient at removing lesions found only on MRI in support of this study and other breast MRI applications. The management of these lesions must be resolved in order to realize the full potential of MRI for screening for breast cancer in women at genetic risk, and for other diagnostic applications.

100.    Sugarbaker, P. H., & Yonemura, Y. (2000). Clinical pathway for the management of resectable gastric cancer with peritoneal seeding: best palliation with a ray of hope for cure. Oncology, 58(2), 96-107.
Abstract: Peritoneal seeding from primary gastric cancer occurs in 10-20% of patients. The diagnosis of this advanced disease is usually not provided by clinical studies prior to abdominal exploration. From the data available in the literature, the surgeon is forced to make an intraoperative judgement concerning the risks and benefits of an aggressive management plan versus supportive care. A strategy has evolved that utilizes peritonectomy and extended gastrectomy to maximally cytoreduce tumor combined with perioperative intraperitoneal chemotherapy. In the current state of the art, the perioperative intraperitoneal chemotherapy is heated and manually distributed to provide uniform treatment to all peritoneal surfaces and the resection site. The pharmacologic parameters have been established and the results of phase II studies are reported. Five-year survival of patients in whom a complete cytoreduction was possible is approximately 10% with a median survival of 12 months. Gastrectomy with peritonectomy to eliminate all visible implants combined with perioperative intraperitoneal chemotherapy should be used in selected patients with primary gastric cancer and carcinomatosis. Copyright 2000 S. Karger AG, Basel [References: 43]

101.    Shaw, L. J., & Miller, D. D. (2000). Defining quality health care with outcomes assessment while achieving economic value. Top Health Inf Manage, 20(3), 44-54.
Abstract: The effectiveness of a procedure is increasingly guided by the evaluation of patient outcomes. Outcomes data is used to develop clinical pathways of care and to define appropriate resource-use levels without sacrificing quality of care. Integration of the economic implications of medical services into an outcome-based guideline allows for the development of disease-management strategies. In cardiovascular medicine, risk reduction is associated with high cost due to the "pay-back" of new technologies and therapies. A major challenge is to define a balance between "high tech" care and cost. This paper devises an outpatient evidence-based guideline using clinical and economic outcomes data for the diagnosis of coronary disease.

102.    Palmer, C. S., Zhan, C., Elixhauser, A., Halpern, M. T., Rance, L., Feagan, B. G., & Marrie, T. J. (2000). Economic assessment of the community-acquired pneumonia intervention trial employing levofloxacin. Clinical Therapeutics, 22(2), 250-64.
Abstract: OBJECTIVE: The purpose of this study was to assess use of a critical pathway designed to manage community-acquired pneumonia more efficiently than its management with conventional therapy. METHODS: Economic outcomes were assessed in conjunction with a cluster-design, randomized, controlled trial. Nineteen participating Canadian hospitals were randomized to implement the critical pathway (n = 9) or conventional therapy (n = 10). The critical pathway included a clinical prediction rule to guide the admission decision, treatment with levofloxacin, and practice guidelines. Patient data on medical resource use, lost productivity, and quality of life were collected prospectively for > or =6 weeks after treatment. Costs were calculated from the government, health care system, and societal perspectives, with imputation of missing outpatient costs and the costs of lost productivity when necessary. Bootstrapping was used to identify 95% CIs for the total cost per patient. RESULTS: The analysis included all eligible patients in the critical pathway (n = 716) and conventional therapy (n = 1027) arms. There were fewer hospital admissions in the critical pathway arm than in the conventional therapy arm, both overall (46.5% vs 62.2%; P = 0.01) and in low-risk patients (33.2% vs 46.8%; P < 0.001). Compared with conventional therapy, hospitals in the critical pathway arm had 1.6 fewer bed days per patient managed (P = 0.05) and used fewer inpatient medical resources. The 2 study arms had similar outpatient, readmission, and lost-productivity costs, and similar quality-of-life outcomes. The critical pathway produced cost savings from all 3 perspectives that ranged from $457 to $994 per patient. CONCLUSIONS: The critical pathway employing levofloxacin resulted in cost savings compared with conventional therapy and did not compromise health outcomes.

103.    Nissan, A., Cohen, A. M., Graham, D., & FitzGerald, A. (2000). Computer-based inpatient medical record in colorectal surgery: pilot study. Diseases of the Colon & Rectum, 43(2), 242-8.
Abstract: PURPOSE: Clinical guidelines and care maps are important tools for improving quality of care and reducing costs. However, problems of quantity, quality, and accessibility of data recorded in the inpatient medical record have not been solved by the implementation of clinical pathways. Variance or "charting by exception" improves legibility, in part. The aim of the present study was to design a computer-based medical record on a database platform to provide legible notes within a clinical guideline and variance charting framework. METHODS: A computerized database program was written, integrating pre-established clinical guidelines into a user-friendly interface according to modification of the charting by exception principles. Patient care guidelines were provided for each postoperative day. After an initial debugging process by entering data from old charts of patients, the software was installed and its function was evaluated on selected patients. The charting time was compared with the standard charting method. Functionality and user friendliness were assessed. RESULTS: After a brief introduction of ten minutes, all users were able to use the software without difficulties. It was found to be functional and user friendly. The charting time was shorter for the computer-based inpatient medical record compared with the charting time of the standard charts. Because all daily notes were printed on standardized forms on a laser printer, legibility was excellent. CONCLUSIONS: The results of this pilot study suggest that the idea of computer-based inpatient medical record integrating an on-line inpatient medical record in a database platform is feasible. Further development and integration with other hospital information systems and the other health-care providers is required.

104.    Martin, G. W., & Younger, D. (2000). Anti oppressive practice: a route to the empowerment of people with dementia through communication and choice. Journal of Psychiatric & Mental Health Nursing, 7(1), 59-67.
Abstract: This short study looks at the issue of anti oppressive practice and the way that it relates to the care of people with dementia. In particular it considers ways in which people can be empowered and given choices around aspects of day-to-day living in a care setting. The study took place over a period of 6 months and utilized the Dementia Care Mapping (DCM) observation process to assess the level of well being of residents in the setting studied. The results can only be seen as a first stage in the process of understanding ways in which people with dementia may be empowered. It is demonstrated that a change of practice developed over the 6 months between the two observation periods. Areas such as communications and day-to-day activities are examined to identify both problems and strategies for such change. The conclusion highlights the need to continue the mapping exercise as a way of ensuring that change is not only maintained but also advanced.   (26 ref)

105.    Lewis, C. K., Wahl, J., Yust, K., & Kaplan, S. (2000). Same-day surgery managed care: monitoring patient and system variances. Journal of Perianesthesia Nursing, 15(1), 12-9.
Abstract: The Same-Day Surgery (SDS) nursing staff at a Midwestern medical center tracked the causative factors for prolonged stays (> 2 hours) in SDS. A review of retrospective data identified that postoperative patient stays averaged between 2 and 3 hours. The top three variances for prolonged stays in SDS were pain, nausea and transportation home. Based on this data, several practice changes that were incorporated to address these variances are reported in this article.

106.    Leong, C. S., Cascade, P. N., Kazerooni, E. A., Bolling, S. F., & Deeb, G. M. (2000). Bedside chest radiography as part of a postcardiac surgery critical care pathway: a means of decreasing utilization without adverse clinical impact. Critical Care Medicine, 28(2), 383-8.
Abstract: OBJECTIVE: To evaluate the use of bedside chest radiography and patient outcome before and after implementation of a cardiac surgery critical care pathway that included guidelines for bedside radiography. DESIGN: A cohort observational study. SETTING: A university hospital in the midwest. PATIENTS: Three groups, of 100 patients each, undergoing cardiac surgery in 1990, 1991, and 1995. INTERVENTION: Introduction of a critical care pathway. MEASUREMENTS: Medical records were retrospectively reviewed in three groups of 100 patients each: before the introduction of the critical care pathway; 2 months after introduction of the pathway in 1991; and 4 yrs after introduction in 1995. Data were analyzed to determine operative risk for each group. Subsequent analyses determined bedside radiography use, total length of hospital stay, and patient outcome (mortality rate, complications requiring intervention, and reoperation) during hospitalization and at outpatient follow-up 15-30 days postdischarge. RESULTS: Total length of hospital stay was shorter for the 1995 group (7.6+/-6.6 days) compared with other groups (prepathway, 11.1+/-10.3 days; 1991 postpathway, 10.2+/-9.6 days; p<.05). The mean numbers of radiographs per patient were as follows: prepathway, 5.1; 1991 postpathway, 5.2; and 1995 postpathway, 3.3. The mean number of radiographs in the 1995 group was significantly lower (p = .02). More patients had the proposed number of two bedside radiographs described in the pathway in the 1995 group compared with the other groups (prepathway, p<.0001; the two-month postpathway group, p = .01). Twenty-three malpositioned catheters/tubes were found in the prepathway and 1991 groups compared with 11 in the 1995 group (p = .02). No statistically significant difference was found in inpatient complications (mediastinal bleeding, pneumothoraces, and pleural effusions), postdischarge complications, reoperations, or mortality rate. CONCLUSION: Introduction of a critical care pathway can decrease the use of bedside radiography without adversely affecting near-term patient outcomes.

107.    Leininger, C. J., & Seaman, L. H. (2000). Selecting clinical quality improvement projects: getting a bigger return for your investment. Top Health Inf Manage, 20(3), 27-34.
Abstract: An urban medical center developed and implemented a process for selecting clinical quality-improvement projects. The process was designed to select projects that would deliver greater returns than had previous projects. The four-step process involved: (1) establishing project selection criteria, (2) identifying potential projects, (3) assigning points and ranking projects, and (4) selecting projects based on rank and available resources. This process won physician commitment and secured administrative support. It identified projects that had unprecedented success in improving clinical outcomes, increasing patient satisfaction, and reducing cost.

108.    Hwang, T. G., Wilkins, E. G., Lowery, J. C., & Gentile, J. (2000). Implementation and evaluation of a clinical pathway for TRAM breast reconstruction. Plastic & Reconstructive Surgery, 105(2), 541-8.
Abstract: Among strategies recently proposed to reduce practice variation, promote quality, and control costs in health care delivery, the concept of the clinical pathway has received considerable attention. Because transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction is a common and often costly intervention, this institution sought to evaluate cost and quality outcomes of a clinical pathways program for this procedure. The TRAM reconstruction clinical pathway was implemented in April of 1996 to standardize postoperative care in this patient population. Outcomes of consecutive pathway cases for the first 14 months of the program were assessed in a retrospective cohort design, by using all nonpathway TRAM cases from the 18 months immediately before pathway implementation as controls. Outcomes assessed included length of hospital stay, postoperative complications, total postoperative charges, and total postoperative costs in relative value units. Data on these dependent variables were collected from hospital charts and billing records. The effects of pathway implementation on the outcomes of interest were analyzed by using analysis of covariance to control for potential confounding by other independent variables, including surgical site (unilateral versus bilateral reconstructions), technique (pedicle versus free TRAMs), timing (immediate versus delayed reconstructions), and patient age. Finally, a comparison of variances in the outcomes of interest between the two groups was analyzed by using an Ftest. For all statistical tests, p values of < or = 0.05 were considered significant. Twenty-nine patients were treated in the TRAM pathway group, whereas the control population included 40 nonpathway patients. After implementation of the TRAM pathway, length of stay decreased from 6.0 to 5.2 days; total postoperative charges were reduced from $8587 to $7744; and total postoperative relative value unit utilization declined from 1686 to 1104. Analysis of covariance showed that the decreases in length of hospital stay and relative value units in the TRAM pathway were statistically significant (p = 0.05 and p = 0.007, respectively). By contrast, no significant increase in complications was observed after pathway implementation. Variability in the TRAM pathway group, as measured by SD, decreased significantly for both length of hospital stay (p = 0.039) and relative value units (p = 0.023). Implementation of the TRAM reconstruction clinical pathway resulted in significant declines in length of hospital stay and total costs. These decreases in resource utilization had no significant effect on postoperative complication rates. Although additional research is needed to further assess the impact of clinical pathways, this approach offers considerable promise for improving the cost-effectiveness of health care.

109.    Holzbeierlein, J. M., & Smith, J. A. (2000). Radical prostatectomy and collaborative care pathways. Seminars in Urologic Oncology, 18(1), 60-5.
Abstract: The purpose of this study was to describe the development, implementation, and evaluation of a collaborative care pathway for radical retropubic prostatectomy. The experience of Vanderbilt University Medical Center is described, and the literature was reviewed. In addition, an example of the radical prostatectomy care pathway is provided for an illustration of a care path. The experience of using collaborative care pathways at Vanderbilt Medical Center has resulted in decreased length of stays, decreased blood utilization, and decreased overall costs. Also, staff satisfaction has improved all without compromising patient care. Collaborative care pathways have been shown to be a cost effective way of standardizing patient care without sacrificing the quality of patient care. In addition, they allow for an easier way to critically evaluate outcomes, costs, and patient and staff satisfaction.

110.    Hayward, E. (2000). Technology overview. Where to start with ICPs: a brief step-by-step guide. British Journal of Healthcare Computing & Information Management, 17(1), 34-35.

111.    Emilien, G., Maloteaux, J. M., Beyreuther, K., & Masters, C. L. (2000). Alzheimer disease: mouse models pave the way for therapeutic opportunities. Archives of Neurology, 57(2), 176-81.
Abstract: Research into the molecular mechanisms of Alzheimer disease (AD) continues to clarify important issues in aberrant protein processing while seeking to identify therapeutic targets. Mutations of genes on chromosomes 1, 14 (presenilins 1 and 2), and 21 (the amyloid-beta [Abeta] amyloid precursor protein [APP]) cause the familial forms of AD that often begin before age 65. An allelic polymorphism on chromosome 19 (apolipoprotein E ) affects the age of onset of the more common forms of sporadic AD. Multiple studies in transgenic mice provide strong evidence to support the view that Abeta amyloid formation is an early and critical pathogenic event: mice expressing pathogenic human APP mutations develop Abeta deposits; coexpression of mutant presenilin genes accelerates the rate of Abeta deposition; and apolipoprotein E plays a role in this process. Thus, the 3 established genetic causes or risk factors for AD affect Abeta deposition. The fact that elevation of the Abeta42/Abeta40 ratio (differing only in 2 amino acids in length) is also linked to amyloid deposition in the APP mice and is temporally linked to cognitive impairment suggests that Abeta42 may be a principal inducing factor of AD. The exact sequence of events is still unknown, but the transgenic models generated so far have shown their usefulness in clarifying this complex part of the pathology. The continuing progress in elucidation of the molecular pathogenesis of AD suggests a range of rational pharmacological interventions for this disorder. The most promising strategy involves the development of approaches to retard, halt, or prevent Abeta-mediated disease progression, and these can now be tested in transgenic animals. [References: 30]

112.    Denehy, J. (2000). Measuring the outcomes of school nursing practice: showing that school nurses do make a difference. Journal of School Nursing, 16(1), 2-4.

113.    Anonymous. (2000). Product directory -- clinical computing & information: integrated care pathways. British Journal of Healthcare Computing & Information Management, 17(1), 36.

114.    Anonymous. (2000). CRITICAL PATH NETWORK. Diabetic ketoacidosis path to automate standing orders: all but very sickest patients treated in outpatient setting. Hospital Case Management, 8(2), 23-26.

115.    Selwood, K. (2000). Integrated care pathways: an audit tool in paediatric oncology. Br J Nurs, 9(1), 34-8.
Abstract: The families of children undergoing treatment for cancer encounter many professionals with varying levels of training, experience and competency. This can lead to variance in the care and advice they receive. The aim of the audit described in this article was to improve care for children with fever and neutropenia by introducing an integrated care pathway. Guidelines for neutropenia were examined and a retrospective analysis of notes undertaken to study what was happening before a pathway was introduced. From this, standards were set and a pathway developed which was introduced to all members of the oncology unit and implemented as part of the children's care. This article will also focus on the audit and evaluation of the pathway. Following this, the pathway has been changed to reflect care and can now be used to introduce new evidence or research in this field.

116.    Selwood, K. (2000). Children's nursing. Integrated care pathways: an audit tool in paediatric oncology. British Journal of Nursing, 9(1), 34-8.
Abstract: The families of children undergoing treatment for cancer encounter many professionals with varying levels of training, experience and competency. This can lead to variance in the care and advice they receive. The aim of the audit described in this article was to improve care for children with fever and neutropenia by introducing an integrated care pathway. Guidelines for neutropenia were examined and a retrospective analysis of notes undertaken to study what was happening before a pathway was introduced. From this, standards were set and a pathway developed which was introduced to all members of the oncology unit and implemented as part of the children's care. This article will also focus on the audit and evaluation of the pathway. Following this, the pathway has been changed to reflect care and can now be used to introduce new evidence or research in this field.   (19 ref)

117.    Ridge, R. A., & Goodson, A. S. (2000). The relationship between multidisciplinary discharge outcomes and functional status after total hip replacement.  Orthopaedic Nursing, 19(1), 71-82.
Abstract: Purpose: To determine changes in functional status after primary total hip replacement and to explore the relationship between functional status and pain and mobility at time of hospital discharge. Design: Descriptive correlational with a prospective cohort. Sample: 21 elective primary total hip arthroplasty patients, ages 40 to 78, in an academic health center. Method: Subjects' functional status was measured using the Sickness Impact Profile and the hip outcome tool (Revised Hip Type Specification Tool 13.1), completed by face-to-face interview approximately 2 weeks prior to hospitalization. Pain and mobility were assessed at time of discharge, and the functional status measures were repeated at 3 months after hospital discharge by mail. Findings: Statistically significant changes were found for physical and psychosocial dimensions of functional status, using the Sickness Impact Profile and the hip outcome tool, between the preoperative and postoperative measures. A significant relationship between mobility and pain at the time of discharge and functional status was not established. Implications: Hospital discharge criteria related to pain and mobility should be used with caution. In addition to pain and mobility information, patient education should reflect knowledge of what can be expected by 3 months postsurgery, including expected and potential improvements in mobility, pain, and ambulation and in nonphysical dimensions, such as sleep, home management, and social interaction. Case management and discharge planning should reflect the wide variance in pain and mobility across patients at time of discharge and the expected gains in specific aspects of functional status after discharge. Research attention should be increased on the identification and application of specific discharge criteria such as pain and mobility levels, and the further development and refinement of nursing-sensitive and practical functional status outcome measures.   (19 ref)

118.    Jacklin, P. B., West, P. A., Sariklis, D., Beech, R., & Maisey, M. N. (2000). An educational tool to illustrate cost-effectiveness in diagnostic pathways for coronary artery disease. MD Computing, 17(1), 49-57.
Abstract: Rapid increases in healthcare costs have led to increased interest in the cost-effectiveness of medical interventions. Coronary artery disease is responsible for a significant share of total healthcare spending, and therefore economic evaluations of medical procedures to treat the condition are potentially very important. We have developed a spreadsheet model as an educational tool that can be used to illustrate cost-effectiveness in the selection of diagnostic pathways (a "work-up" strategy of tests designed to reach a final diagnosis) for coronary artery disease. The model, in Microsoft Excel, is easy to use, requiring no specialist computer knowledge. It is menu-driven and the user navigates the model via a number of on-screen buttons. A data entry screen allows the user to customize the data for the key model parameters, making it possible to take into account location-specific features. The data entry screen also allows the user to undertake sensitivity analysis and rate "what if" scenarios. The model demonstrates how sensitive the cost-effectiveness of different diagnostic pathways is to the pretest probability of disease. This package could also be used as a decision support tool, although it is important to recognize some of its limitations for this purpose.

119.    de Graffenried Ruffin, M. Jr. (2000). Building a framework to transform health care. Physician Exec, 26(1), 46-50.
Abstract: Advances in information technology are helping clinicians to realize the promise of evidence-based medicine, which includes benchmarking, outcomes monitoring, predictive modeling, and clinical pathways. By integrating individual clinical expertise and the best available research, physicians can apply the disciplines and techniques of clinical research to their practice of medicine, one patient at a time. Evidence-based medicine also allows organizations to move forward with continuous clinical quality improvement programs. Standards, open systems, data warehouses, and evidence-based medicine help a health care delivery system obtain the technical infrastructure, decision-making processes, analytical skills, clinical databases, predictive models, and clinical pathways. With this information technology (1) physicians can practice evidence-based medicine and (2) the delivery system can profile clinicians' practice habits for managed care contracting and continuous clinical quality improvement.

120.    Young, J. S. (2000). Cerebral perfusion pressure or intracranial pressure? [letter; comment]. Journal of Neurosurgery, 92(1), 191-2.
Notes: Comments: Comment on: J Neurosurg 2000 Jan;92(1):1-6

121.    Willis, B., Kim, L. T., Anthony, T., Bergen, P. C., Nwariaku, F., & Turnage, R. H. (2000). A clinical pathway for inguinal hernia repair reduces hospital admissions. Journal of Surgical Research, 88(1), 13-7.
Abstract: BACKGROUND: Clinical pathways have been advocated as a means to improve and standardize patient care while reducing costs through improved efficiency. This study examines the hypothesis that development of a clinical pathway reduces hospital admissions in a Veterans Affairs (VA) medical center. MATERIALS AND METHODS: For the year prior to June 1997, 168 elective inguinal herniorrhaphies were performed. This constituted the prepathway (pre-P) group. One hundred ninety-six elective inguinal herniorrhaphies were performed during the year following institution of the clinical pathway-the postpathway (post-P) group. RESULTS: Hospital admissions were compared between the two groups. In the pre-P group 61 of the 168 patients (36%) were admitted while 29 of the 196 patients (15%) in the post-P group were admitted (P < 0.001). In the pre-P group 27 of the 53 patients reviewed (51%) had either no justification or inadequate justification for admission. In the post-P group 8 of the 29 patients admitted (28%) had inadequate justification (pre-P vs post-P, P = 0.124). Common reasons for admission included pain, perioperative complications, and concurrent medical problems or surgical procedures. The most common single cause other than pain was urinary retention. The average age of patients requiring admission was greater both pre-P and post-P. CONCLUSIONS: We conclude that institution of a clinical pathway for inguinal herniorrhaphy decreased hospital admissions. The reasons for this decrease are probably multifactorial and include improvements in physician and staff awareness. The decrease in unnecessary admissions should result in more efficient use of hospital resources.

122.    Todaro, T., & Schott-Baer, D. (2000). Plan faster, healthier recovery after orthopedic surgery. Nursing Management (Chicago), 31(1), 24-6.
Abstract: Two hospitals--one community and one urban--use clinical pathways to streamline patient care. They lower the average length of stay by 41% and 30%, respectively, and shrink clinical and surgical complications.

123.    Schwartz, D. B., & Gudzin, D. (2000). Preadmission nutrition screening: expanding hospital-based nutrition services by implementing earlier nutrition intervention. Journal of the American Dietetic Association, 100(1), 81-7.
Abstract: The need to screen patients earlier than within the first 24 hours of hospital admission has resulted in the development of preadmission nutrition screening. At Providence Saint Joseph Medical Center (PSJMC), a 455-bed acute-care facility, this procedure has been used since 1994. The preadmission screening method was developed because of the use of critical pathways for patients in specific diagnosis-related groups. Critical pathways specified that registered dietitians must assess these patients within 24 hours of admission at PSJMC. However, at that time there was minimal data in the chart from which to assess the patient's nutritional status and the ability to interview the patient was often limited as a result of intubation or postoperative pain. Family members were not always available at the hospital to discuss a patient's preadmission nutritional status. To address this problem, we developed a system to call people at home before their admission to the hospital to obtain specific nutrition information. To analyze the effectiveness of the procedure, the Food and Nutrition Services Department developed a process to assess this method of screening and to improve the system. Patients were enrolled in a study over a 1-month period, demographics were identified for this sample population, and patient satisfaction was determined via an interview conducted by a dietetic technician after the patient was admitted. Most patients found this to be a very helpful process and an example is presented here on the role of preadmission nutrition screening in improving patient outcome. To better define the population of the case study presented, additional information was gathered on a second study group of patients screened before admission who were admitted for hip and knee surgery, one of the specific diagnosis-related groups with a critical pathway. Our findings indicate that preadmission nutrition screening has the potential to improve patient outcomes by increasing nutrient intake before their hospital admission, reducing hospitalization length, and enhancing patient satisfaction during their hospital stay.

124.    Schriefer, J., Engelhard, J., DiCesare, L., Miller, M., & Schriefer, J. (2000). Merging clinical pathway programs as part of overall health system mergers: a ten-step guide. Spectrum Health. Joint Commission Journal on Quality Improvement, 26(1), 29-38.
Abstract: BACKGROUND: Mergers, acquisitions, and reorganizations can be stressful and accompanied by ambivalence, confusion, and uncertainty. Providing clear and simple steps for merging clinical pathways may help organizations move through the transition process more smoothly. The ten steps according to which Spectrum Health merged its pathway program-conduct an inventory of previous efforts, plan for the ideal program, bring staff together early in the merger process, decide on a common format, standardize the development and revision process, standardize a reporting tool, create a clinical pathway manual, implement an educational plan, present the program to key customers, and appoint an advisory group-need not be done sequentially. The ten-step pathway merger program uses pathways as a means to improve the quality of the care provided, with a focus on multidisciplinary clinical pathway teamwork. Before the merger, the two hospital systems' pathway programs used different approaches to operations and pathway format. When the announcement to merge came in September 1997, steps to merge the clinical pathway programs began. DISCUSSION: More than two years into the merger, Spectrum Health continues to struggle with the evolution of the health system. Clinical pathways represent just one of the significant and extensive issues related to organizational mergers; organizational values, finances, vision, mission, customer relations, strategic priorities, and people issues are a few of the others. Focusing on merging programs such as clinical pathway programs can help put one large piece of the merger puzzle in place and reduce some of the ambiguity associated with all mergers. Executive support is critical to the success of the clinical pathway program.

125.    Peterson, J. L., & Hartman, H. W. (2000). Clinical practice. A pathway for patients who die within a week of hospice admission. International Journal of Palliative Nursing, 6(1), 39-42.
Abstract: Care pathways have recently been developed for hospice patients who die within one week of admission. This development was motivated by a number of factors. First, under managed care cost constraints, it is sometimes difficult to obtain early hospice admission approval because of certain reimbursement regulations. Second, patient and family wishes change during the illness trajectory as patients move through the stages of death and dying. Third, and most important to the care-giver is that the philosophy adopted within care pathways advocates that patients should not suffer at the end of life. This article outlines the rationale for the formulation of care pathways and describes a care pathway developed for a specific group of patients.   (7 ref)

126.    Peck, C., & Schriefer, J. (2000). Critical path network. Parent to parent program paths minimize OB complications. Hospital Case Management, 8(1), 7-10.

127.    McMahon, L. W., Sealing, P. A., Mahoney, D. H. Jr, Bowman, W. P., & Sandler, E. (2000). Description of a multihospital process to develop a care path for the child with acute lymphoblastic leukemia. Journal of Pediatric Oncology Nursing, 17(1), 33-44.
Abstract: This article describes the National Association of Children's Hospitals and Related Institutions (NACHRI) collaborative group process used to create a multihospital care path for the child with acute lymphoblastic leukemia (ALL), and presents strategies for implementation and future direction. Although most children in the United States with cancer are treated according to National Cancer Institute-sponsored comprehensive protocols, there is a wide variation in the implementation of protocols by physicians and hospitals. The development of this care path was based on evidence from the literature, review of practice patterns, expert opinion, and group participant consensus building. The resulting 4-day care path was organized into six categories of care (e.g., assessment practices, diagnostic tests, teaching, and discharge planning). Discharge criteria are stated at the beginning of the care path to emphasize the planning process immediately on admission. Clinical outcomes, skill and knowledge outcomes for the parent and child, and home assessment considerations are also included. Strategies to create change and gain support of various stakeholders toward implementation of the care path are presented. The strength of the resulting care path is possible in large part because the multihospital group process brought professionals from around the country together to discuss, analyze, and reach consensus on the practices related to the child with ALL. The group process enabled the development of a care path that goes beyond a traditional care path developed by a single institution.

128.    McLean, S. R., & Mahaffey, S. M. (2000). Implementing a surgical balanced scorecard. Surgical Services Management, 6(1), 43-44, 46-47.

129.    Heslop, L., Elsom, S., & Parker, N. (2000). Improving continuity of care across psychiatric and emergency services: combining patient data within a participatory action research framework. Journal of Advanced Nursing, 31(1), 135-43.
Abstract: Presented with the concerns of emergency department nurses about providing appropriate and co-ordinated care for patients seeking mental health services, a Monash University School of Nursing, Victoria, Australia, research team chose a participatory action research strategy. Jointly executed with staff from the Peninsula Health Care Network, the research process brought together in a number of fora multiple disciplines involved in the care and management of psychiatric patients. The participatory action research process itself was the first step in remedial action. Through it, participants and management gained a firmer view of the issues facing Frankston Hospital Emergency Department staff in dealing with psychiatric patients, and in securing their access to suitable pathways of care. Other research outcomes included: a compilation of summary statistics showing patterns of use by psychiatric patients of Frankston Hospital's Emergency Department; beginning discussions about pathways of care for these patients; and the development of a screening tool to be used by the triage nurse for at-risk psychiatric patients presenting to the Emergency Department.

130.    Goldstein, L. B., Hey, L. A., & Laney, R. (2000). North Carolina stroke prevention and treatment facilities survey. Statewide availability of programs and services. Stroke, 31(1), 66-70.
Abstract: BACKGROUND/PURPOSE: The aim of this study was to determine the statewide availability of facilities and programs for stroke prevention and treatment to identify underserved regions and target educational efforts. METHODS: A single-page survey was mailed to the directors of each inpatient medical facility in North Carolina. Data collected included the availability of selected diagnostic tests, programs, and services. Facilities were categorized as providing basic (emergency department, brain CT, treatment with rtPA, transthoracic echocardiography, carotid ultrasonography, cerebral angiography, carotid endarterectomy) or advanced (basic services plus brain MRI, MR angiography, transesophageal echocardiography, transcranial Doppler ultrasonography, interventional radiology) services. The availability of other programs and services, including having a neurologist on staff, organized anticoagulation clinics, inpatient rehabilitative services, diffusion-weighted MRI, community awareness and rapid stroke identification programs, stroke teams, stroke acute care units or an equivalent, and the use of stroke-care maps, were also determined. RESULTS: Complete responses were obtained from all of the state's 125 inpatient medical facilities. Overall, 97% of the state's population resided in counties with a hospital providing at least some stroke prevention or treatment procedures or services. Full basic services were provided by 23 facilities located in 19 of the state's 100 counties and were available to 52% of the state's population based on county of residence; advanced services were provided by 8 facilities located in 7 counties and were available to 26% of the state's population based on county of residence. Stroke-care maps were used in 83% of basic or advanced centers versus 23% of other hospitals (P<0.001), stroke teams were organized in 48% versus 12% (P=0.001), stroke units or equivalents were available in 61% versus 9% (P<0.001), rapid patient identification programs were in place in 57% versus 9% (P<0.001), and community awareness programs were in place in 57% versus 21% (P=0.005). CONCLUSIONS: Only 52% of the state's population reside in counties with hospitals providing full basic services; by expanding these services to only 6 additional facilities and thereby encompassing the state's 50 most populous counties, this proportion would be increased to 84%. Services that may improve outcomes and reduce costs (eg, stroke teams, stroke units, care maps) are not widely used, even in centers with full basic capabilities. Targeting educational efforts to these centers could improve the overall level of stroke care for the majority of the state's population. The study serves as a model that can be applied to other states and regions.

131.    Dell'Orfano, J. T., Kramer, R. K., & Naccarelli, G. V. (2000). Cost-effective strategies in the acute management of atrial fibrillation. Current Opinion in Cardiology, 15(1), 23-8.
Abstract: Atrial fibrillation is the most common sustained arrhythmia likely to be encountered in clinical practice. It is associated with significant morbidity and mortality. The treatment of patients with atrial fibrillation can be complex and costly, especially when patients are hospitalized for acute management of this arrhythmia. In this review, we summarize current approaches to the acute management of atrial fibrillation with an emphasis on the most cost-effective approaches. We review acute methods of heart rate control and cardioversion, including pharmacologic and other minimally invasive strategies. We believe that the most cost-effective approaches may require the use of standardized clinical pathways. This may help to ensure that patients with acute atrial fibrillation receive the most effective and efficient care. [References: 28]

132.    Daiski, I. (2000). The road to professionalism in nursing: case management or practice based in nursing theory? Nursing Science Quarterly, 13(1), 74-9.

133.    Beger, D., Messenger, F., & Roth, S. (2000). Self-administered medication packet for patients experiencing a vaginal birth... reprinted from D. Beger, F. Messenger, and S. Roth, Self-administered medication packet for patients experiencing a vaginal birth, Journal of Nursing Care Quality, Vol. 13, No. 4, 47-59, &#169; 1999, Aspen Publishers, Inc. Pharmacy Practice Management Quarterly, 19(4), 51-63.

134.    Anonymous. (2000). How to achieve QI cooperation from health system physicians: protocol program worked for this 5-hospital system... quality initiative. Healthcare Benchmarks, 7(6), 61-64.

135.    Anonymous. (2000). Give wound care a boost with new clinical pathway. Home Care Quality Management, 6(1), 9-10, 12 insert 4p.

136.    Rothstein, H., & Tonges, M. C. (2000). Beyond the significance test in administrative research and policy decisions. Journal of Nursing Scholarship, 32(1), 65-70.
Abstract: PURPOSE: To describe confidence interval (CI) analysis and show how it can be used in administrative decisions. ORGANIZING CONSTRUCT: Statistical significance testing should be supplemented, if not replaced, by effect size (ES) estimation and confidence interval analysis. Hypothesis testing based on the statistical significance test is the dominant paradigm in statistics; however, this approach has inherent problems which can ultimately diminish the usefulness of research for operational decisions. After identifying major difficulties with significance testing, the authors use hypothetical examples to demonstrate how ES and CI analysis provide more informative answers to nursing administrative research questions. CONCLUSIONS: CI analysis provides the basis for both improving the interpretation of findings from individual studies and for facilitating the analysis of cumulative evidence. By clarifying the meaning of results, CI analysis can increase the relevance and usefulness of research for health care executives and practitioners.  (31 ref)

137.    Wong, C., Visram, F., Cook, D., Griffith, L., Randall, J., O'Brien, B., & Higgins, D. (2000). Development, dissemination, implementation and evaluation of a clinical pathway for oxygen therapy. Canadian Medical Association Journal, 162(1), 29-33.
Abstract: Background: Oxygen is commonly administered to patients in hospital, but prescribing and monitoring of such therapy may be suboptimal. The objective of this study was to develop, disseminate, implement and evaluate a multidisciplinary clinical pathway for the administration of oxygen. Methods: The authors developed a clinical pathway for the ordering, titration and discontinuation of oxygen, which was disseminated through teaching sessions, in-service training sessions and information posters in a medical clinical teaching unit (CTU). Implementation of the pathway was ensured by means of reminders and patient-centred audit and feedback to CTU nurses and house staff. During a 3-month intervention phase, consecutive patients requiring supplemental oxygen were treated according to the pathway. During a 1-month 'wash-out' phase followed by a 3-month non-intervention phase, patients were treated at the discretion of the CTU team. Clinical and economic data were collected in both phases. Results: In the 2 phases, patient characteristics, the concentration and duration of oxygen prescribed, the frequency of oxygen saturation monitoring, the frequency of arterial blood gas testing and the clinical outcomes were similar. However, there were more discontinuation orders in the intervention phase (p < 0.001). In the intervention phase, costs were higher for monitoring of oxygen saturation ($44.95/patient v. $36.17/patient, p = 0.048) and for order transcription ($2.71/patient v. $1.28/patient, p < 0.001); total costs, including those for personnel, were also higher in the intervention phase ($76.93/patient v. $56.67/patient, p = 0.02). The cost of education about the oxygen pathway was $45.71/patient. When the education cost was included, the total cost of oxygen therapy during the intervention phase was $122.64/patient; this was significantly higher than the total cost of oxygen therapy during the non-intervention phase ($56.67/patient) (p < 0.001). Interpretation: This multidisciplinary, multimethod oxygen pathway led to changes in oxygen-prescribing behaviour, consumed more resources than standard management and was not associated with changes in patient outcome. Appropriate management of oxygen prescribing and monitoring by physicians and nurses takes time and costs money.  [References: 18]

138.    Warren, R. M. L., & Hayes, C. (2000). Localization of breast lesions shown only on MRI - A review for the UK study of MRI screening for breast cancer. British Journal of Radiology, 73(866), 123-132.
Abstract: The UK study of screening for breast cancer compares mammography and dynamic contrast enhanced MRI of the breast in women at high genetic risk of developing cancer. Owing to the high sensitivity of MR in the breast, it is anticipated that some lesions will be visible only on MR. A key issue for the study is how to localize these lesions for histological verification and removal. This article reviews available methods and describes the current UK expertise and recent European developments. The use of MR compatible wires and markers has been explored in a phantom. The use of these markers in vivo is demonstrated in a case imaged by MR and mammography and further discussed. The susceptibility artefacts produced on MRI, and technical properties associated with these needles, wires and markers are discussed. The clinical pathway by which these lesions will be worked up for the study, and the quality control procedures for keeping the number of such biopsies to a minimum, are described. There is an urgent need for further centres in the UK to become proficient at removing lesions found only on MRI in support of this study and other breast MRI applications. The management of these lesions must be resolved in order to realize the full potential of MRI for screening for breast cancer in women at genetic risk, and for other diagnostic applications.  [References: 43]

139.    Tucker, S. M., Canobbio, M. M., Paquette, E. V., & Wells, M. F. (2000).  Patient care standards: collaborative planning & nursing interventions. St. Louis, MO: Mosby-Year Book.

140.    Thomas, L., Cullum, N., McColl, E., Rousseau, N., Soutter, J., & Steen, N. (2000). Guidelines in professions allied to medicine. The Cochrane Library (Oxford) ** 2000 Issue 1 (14 P) (25 Ref) .
Abstract: (Date of most recent substantive amendment: 24 November 1998). Background and objectives: To identify rigorous evaluations of the introduction of clinical practice guidelines in nursing (including health visiting), midwifery and other professions allied to medicine. Both hospital and community sectors were included. To determine the effectiveness and efficiency of introducing clinical practice guidelines targeting nursing, midwifery and professions allied to medicine to promote improved professional practice and patient outcomes. Search strategy: Relevant studies were located using a variety of electronic databases (eg Medline [1975-1996], Embase [1980 -1996], Cinahl [1982-1996]) and personal contact with content area experts. Selection criteria: Study design: randomised controlled trials (RCTs); interrupted time series (ITS) studies and controlled before and after (CBA) studies. Participants: any of the following health care disciplines: nursing, midwifery, health visiting, chiropody, speech and language therapy, physiotherapy, occupational therapy, dietetics, clinical psychology, pharmacy and radiography. Interventions: the introduction of clinical practice guidelines. Outcomes: any measure of professional performance or patient outcomes. Data collection and analysis: Comparisons: all studies that evaluated the effectiveness of guidelines plus dissemination/implementation strategies against a non-intervention control (comparison 1), or that evaluated different dissemination and implementation strategies (comparison 2). During the review, we identified a subset of studies that evaluated role substitution supported by clinical guidelines; they were included as a post-hoc comparison in the review (comparison 3). Data extraction and quality assessment were undertaken independently by two reviewers using a data checklist following standard methods described by the Cochrane Effective Practice and Organisation of Care Group (EPOC). Data on methods, participants, interventions and outcomes were extracted. It was impractical to examine the impact of interventions quantitatively in specific subgroups of studies because of the heterogeneity of clinical area, study design, source and format of interventions, processes and outcomes measured and participating health professionals. We therefore opted to report effects on process and outcome of care in the same way they were reported in the original papers. Main results: Eighteen studies met all inclusion criteria including 13 RCTs, three ITS studies and two CBA studies. The reporting of study methods was inadequate for all studies. In all but one study, nurses were the targeted professional group; one study was aimed solely at dieticians. Various behaviours were targeted included the management of hypertension, low back pain and hyperlipidaemia. Nine studies examined comparison 1: three out of five studies observed improvements in at least some processes of care and six out of eight studies observed improvements in outcomes of care. Only one study included a formal economic evaluation, with equivocal findings. Three studies examined comparison 2; it was difficult to draw firm conclusions from the identified studies because of poor methods. Six studies examined comparison 3: these studies generally supported the hypothesis of no difference between nurse-protocol driven and physician care. Reviewers' conclusions: Findings from the 18 studies identified provide some evidence that guideline-driven care can be effective in changing the process and outcome of care provided by professions allied to medicine. Significant improvements in the outcome of care were found in six out of eight studies comparing the introduction of guidelines to a no guideline control. The three studies comparing two or more dissemination and implementation strategies were compromised by poor methods; as a result it is difficult to draw firm conclusions from these studies. The findings from the six studies that examined the ability of clinical guidelines to enable role substitution generally support the effectiveness of this intervention. However, caution is needed in generalising findings to other professions and settings. [CINAHL Note: The Cochrane Collaboration systematic reviews contain interactive software that allows various calculations in the MetaView.]

141.    Taik Gun Hwang, Wilkins, E. G., Lowery, J. C., & Gentile, J. (2000). Implementation and evaluation of a clinical pathway for TRAM breast reconstruction. Plastic & Reconstructive Surgery, 105(2), 541-548.
Abstract: Among strategies recently proposed to reduce practice variation, promote quality, and control costs in health care delivery, the concept of the clinical pathway has received considerable attention. Because transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction is a common and often costly intervention, this institution sought to evaluate cost and quality outcomes of a clinical pathways program for this procedure. The TRAM reconstruction clinical pathway was implemented in April of 1996 to standardize postoperative care in this patient population. Outcomes of consecutive pathway cases for the first 14 months of the program were assessed in a retrospective cohort design, by using all non-pathway TRAM cases from the 18 months immediately before pathway implementation as controls. Outcomes assessed included length of hospital stay, postoperative complications, total postoperative charges, and total postoperative costs in relative value units. Data on these dependent variables were collected from hospital charts and billing records. The effects of pathway implementation on the outcomes of interest were analyzed by using analysis of covariance to control for potential confounding by other independent variables, including surgical site (unilateral versus bilateral reconstructions), technique (pedicle versus free TRAMs), timing (immediate versus delayed reconstructions), and patient age. Finally, a comparison of variances in the outcomes of interest between the two groups was analyzed by using an F test. For all statistical tests, p values of <= 0.05 were considered significant. Twenty-nine patients were treated in the TRAM pathway group, whereas the control population included 40 nonpathway patients. After implementation of the TRAM pathway, length of stay decreased from 6.0 to 5.2 days; total postoperative charges were reduced from $8587 to $7744; and total postoperative relative value unit utilization declined from 1686 to 1104. Analysis of covariance showed that the decreases in length of hospital stay and relative value units in the TRAM pathway were statistically significant (p = 0.05 and p = 0.007, respectively). By contrast, no significant increase in complications was observed after pathway implementation. Variability in the TRAM pathway group, as measured by SD, decreased significantly for both length of hospital stay (p = 0.089) and relative value units (p = 0.028). Implementation of the TRAM reconstruction clinical pathway resulted in significant declines in length of hospital stay and total costs. These decreases in resource utilization had no significant effect on postoperative complication rates. Although additional research is needed to further assess the impact of clinical pathways, this approach offers considerable promise for improving the cost-effectiveness of health care.  [References: 13]

142.    Swanson, C. E., Yelland, C. E., & Day, G. A. (2000). Clinical pathways and fractured neck of femur. Medical Journal of Australia, 172(9), 415-416.

143.    Stoeckle, J. D. (2000). The market pushes education from ward to office, from acute to chronic illness and prevention: Will case method teaching-learning change? Archives of Internal Medicine, 160(3), 273-280.

144.    Skillman, J. J., Paras, C., Rosen, M., Davis, R. B., Kim, D., & Kent, K. C. (2000). Improving cost efficiency on a vascular surgery service. American Journal of Surgery, 179(3), 197-200.
Abstract: Background: A vascular task force (VTF) consisting of two vascular surgeons and other key personnel was established to reduce costs and improve efficiency in the management of patients on a vascular surgery service. Methods: The VTF met monthly beginning in 1994 to study and implement changes in the management of patients with (1) abdominal vascular, (2), carotid endarterectomy (3) distal bypass, and (4) other vascular procedures, including amputations. Length of stay, and fixed and variable costs were assessed for change over time using Pearson correlation coefficients. Results: Improvements in efficiency (length of stay) and decreases in costs (fixed and variable costs) from fiscal year 1993 to fiscal year 1996 were significant for the total group of vascular patients (P <=0.001), with some intergroup differences. The major improvements were in the abdominal vascular and carotid endarterectomy groups, where length of stay and fixed and variable costs were reduced significantly (P <=0.01). Management of distal bypass and other vascular surgery patients showed less striking improvement. Conclusion: Vascular surgeons in collaboration with other dedicated personnel involved in the care of vascular patients can improve efficiency and reduce costs. Advances were greatest in patients who required operations for carotid and abdominal vascular disorders and least for patients who required distal bypasses and other vascular procedures. Copyright (C) 2000 Excerpta Medica Inc.  [References: 9]

145.    Ruchholtz, S. (2000). The Trauma Registry of the German Society of Trauma Surgery as a basis for interclinical quality mangement. A multicenter study of the German Society of Trauma Surgery. Unfallchirurg, 103(1), 30-37.
Abstract: Based on the 'Trauma Registry' of the German Society of Trauma Surgery, an interclinical quality management (QM) system was implemented. The principles of the QM system as well as the differences in the quality of outcome and treatment are presented. The analysis uses the data on 2,069 severely injured (ISS = 22 +/- 14) patients from 20 hospitals collected prospectively and anonymously between 2/93 and 12/97. Outcome quality was analyzed by the TRISS method and Z-statistics. The Z-value of the whole series was -0.24. There were three hospitals with more than 150 patients that had a Ps value calculated by the TRISS method. Clinic A had a good (-2.49), clinic B an average (-0.3) and clinic C (3.62) an adverse Z-value. The assessment of treatment quality was performed by criteria concerning both preclinical and acute clinical phases. Clinic C had a prolonged preclinical treatment time (90 min vs 62 min in clinic A) for severely injured (ISS > 15) patients. At the same time, the preclinical intubation rate for severe thoracic trauma (AIS > 3) was lower (44%) in clinic C than in A (62%). With 14 min clinic A had the shortest time until basic radiological and ultrasound diagnostics were completed (X-rays of chest and pelvis and abdominal ultrasound) in cases of severe blunt trauma (ISS > 15), compared to 54 min in clinic B or 31 min in clinic C. Also, cranial computed tomography for severe traumatic brain injury (GCS < 9) was applied significantly faster in clinic A (after 36 min) than in clinic C (after 62 min). Delayed diagnoses were defined as the difference between the ISS at discharge and the ISS at completion of diagnostics in the emergency department; this criterion was met best by clinic A with an ISS difference of two patients compared to five in clinic B and four in clinic C. The hospitals participating in the Trauma Registry receive an annual analysis of their preclinical and acute clinical performance. Thus, every hospital can analyze and improve the quality of treatment based on reliable data that show which parts of the process have to be optimized. Furthermore, the data allow a comparison of the average and optimal results of the whole series.  [References: 32]

146.    Roberts, G. (2000). Linking with primary care groups. Journal of Clinical Excellence, 1(4), 259.

147.    Petrou, S., Coyle, D., & Fraser, W. D. (2000). Cost-effectiveness of a delayed pushing policy for patients with epidural anesthesia. American Journal of Obstetrics & Gynecology, 182(5), 1158-1164.
Abstract: OBJECTIVE: The purpose of this study was to estimate the economic efficiency of a policy of delayed pushing for nulliparous women who have full dilatation while they are under epidural anesthesia. STUDY DESIGN: A cost- effectiveness evaluation was based on a randomized controlled trial. Resource use and clinical effectiveness data were collected for 1862 women who were randomly allocated to either a delayed pushing group (n = 936) or an early pushing group (n = 926). Costs (in 1997 Canadian dollars) were collected for each item of resource use. Sensitivity analysis was used to examine the robustness of the main results. RESULTS: Delayed pushing was effective at reducing the number of difficult deliveries (relative risk, 0.79; 95% confidence interval, 0.66 to 0.95). The mean cost of intrapartum care was significantly higher in the delayed pushing group ($625.86 vs $557.64; P < .0005). There were no significant differences in mean costs of postnatal care ($2146.67 vs $2133.54; P = .871) or total hospital care ($2772.53 vs $2691.18; P = .324). The incremental cost per difficult delivery prevented was estimated at $1743.06. The incremental cost-effectiveness ratio remained fairly robust with variations in the values of key parameters incorporated into the sensitivity analysis. CONCLUSIONS: The results of this economic evaluation should inform decision makers determining whether to advocate a policy of delayed pushing for nulliparous women who have full dilatation while they are under epidural anesthesia.  [References: 20]

148.    Orfield, K. (2000). Increasing the laboratorian's role in assessing patient outcomes. Laboratory Medicine, 31(1), 16-21.
Abstract: The work done in the laboratory is a critical piece in improving patient outcomes and a reason for laboratorians to take on a larger role in outcome measurement. Learn what may be expected of you on an outcomes team. Selecting measurement projects, implementing clinical pathways, identifying data sources, and assessing data are some of the ways you can contribute.  [References: 4]

149.    Ohlstein, E. H., Ruffolo, R. R. Jr, & Elliott, J. D. (2000). Drug discovery in the next millennium. Annual Review of Pharmacology & Toxicology, 40, 177-191.
Abstract: Selection and validation of novel molecular targets have become of paramount importance in light of the plethora of new potential therapeutic drug targets that have emerged from human gene sequencing. In response to this revolution within the pharmaceutical industry, the development of high- throughput methods in both biology and chemistry has been necessitated. This review addresses these technological advances as well as several new areas that have been created by necessity to deal with this new paradigm, such as bioinformatics, cheminformatics, and functional genomics. With many of these key components of future drug discovery now in place, it is possible to map out a critical path for this process that will be used into the new millennium.  [References: 38]

150.    Ogushi, Y. (2000). Developments of critical path for cancer chemotherapy: Pilot study. Japanese Pharmacology & Therapeutics, 28(2), 159-163.

151.    Nozue, M., Maruyama, T., Imamura, F., Fukue, M., & Kamiyama, K. (2000). Introduction of critical path guidelines into cases performed distal gastrectomy. Japanese Journal of Gastroenterological Surgery, 33(4), 507-511.
Abstract: To prepare for the change in the health insurance system in Japan, critical path guidelines have been introduced to our hospital. In our surgical department, critical path for distal gastrectomy has also been inducted since autumn in 1998. To evaluate the effect of the induction, days in hospital and points for health insurance were compared between 10 cases treated using the critical path guidelines and 17 cases without critical path. The path prescribes the clinical course as follows : preoperative exam at outpatient clinic, 2 days stay before operation, 16 days stay after operation. As a result, about 70% of patients followed this path. The average hospital stay has significantly decreased from 36 to 27.3 days after induction of the path. Average points for health insurance also significantly decreased from 165,800 to 133,900. Adjusting points by days in hospital to 19 days, showed that the medical care itself was also standardized under the critical path.  [References: 3]

152.    McQueen, M. J. (2000). Evidence-based medicine: Its application to laboratory medicine. Therapeutic Drug Monitoring, 22(1), 1-9.
Abstract: The current health care environment of cost-cutting highlights the need to reinforce the contribution of laboratory medicine to improvement in health care. This must be a patient-focused activity using continuous quality improvement, a familiar concept in laboratory practice. Involvement in the creation of clinical practice guidelines, care maps, and outcome measures will place laboratory medicine in the circle of continuous quality improvement. The laboratory must provide strong evidence that tests contribute to better overall resource utilization. Laboratory Information Systems can be used to better integrate laboratory data with clinical, diagnostic, pharmaceutic, statistical, and financial information. Improving laboratory utilization requires clear demonstrations of appropriate versus inappropriate laboratory use, and instructions on implementing appropriate use. The education of laboratory professionals should include search strategies, understanding the diagnostic accuracy of medical tests, and the application of systematic reviews and meta-analysis. With the rapid increase in the data base supporting evidence-based laboratory medicine, there is a significant challenge in translating the existing knowledge into practice. There is also a need for a cooperative strategy between the diagnostics industry and the laboratory medicine profession to provide evidence of the added value of laboratory testing. There is a significant role in developing the academic basis of the unique aspects of evidence-based laboratory medicine.  [References: 73]

153.    Lantelme, P., Lo, M., & Sassard, J. (2000). Renin-Angiotensin system in two genetically normotensive strains of Lyon rats. American Journal of Hypertension, 13(3), 283-289.
Abstract: Compared to the Lyon normotensive (LN) controls, adult Lyon hypertensive rats (LH) exhibit a renin-angiotensin system (RAS) dependent hypertension despite a low renin secretion. This discrepancy could be explained by the elevated slow pressor response to angiotensin II (AII) found in LH rats compared to LN controls. To evaluate more precisely the pathophysiological importance of this increased response, the present work aimed at determining whether the characteristics of the RAS were identical in LN and low blood pressure (LL) rats, the other normotensive control strain simultaneously selected with LH rats. Plasma and Kidney renin and prorenin were measured in 11-week-old LN and LL rats. Aortic blood pressure (BP) was recorded at 15 weeks of age in freely moving rats of both strains either untreated or having received an angiotensin converting enzyme inhibitor, perindopril (3 mg/kg/day orally) since the age of 3 weeks. Acute dose-response curves were constructed for AII and norepinephrine (NE). The long-term pressor effects of AII (200 ng/kg/min) and NE (1000 ng/kg/min) were measured after chronic infusions in perindopril-treated LN and LL rats. LN and LL rats exhibited similar mean BP level before (114 +/- 2 and 117 +/- 2 mm Hg, respectively) and after perindopril treatment (91 +/- 3 and 93 +/- 1 mm Hg, respectively). Plasma and kidney renin and prorenin were decreased in LL rats. In acute conditions, LL rats exhibited an unspecific hypersensitivity to AII and NE. Chronically given AII exerted a greater pressor effect in LL than in LN rats after 4 weeks (113 +/- 3 v 97 +/- 5 mm Hg in LL and LN rats respectively, P < .05) and, even more, after 8 weeks of infusion (144 +/- 9 v 124 +/- 4 mm Hg in LL and LN rats respectively, P < .05). The NE was devoid of chronic pressor effects. In conclusions, 1) the increased slow pressor response to AII may not be a critical pathogenetic factor in the development of hypertension, as it also exists in normotensive LL rats; 2) LN and LL rats have the same normal BP despite marked differences in their RAS, thus suggesting that there could be several forms of normotension as known for hypertension; and 3) the simple comparison between one genetically hypertensive strain and one single normotensive control strain does not allow one to conclude that a phenotypic difference is of pathophysiological significance. (C) 2000 American Journal of Hypertension, Ltd.  [References: 20]

154.    Klodell, C. T., Carroll, M., Carrillo, E. H., & Spain, D. A. (2000). Routine intragastric feeding following traumatic brain injury is safe and well tolerated. American Journal of Surgery, 179(3), 168-171.
Abstract: Background: Delayed gastric emptying following traumatic brain injury (TBI) has led some to advocate jejunal feeding. Our purpose was to review our experience with percutaneous endoscopic gastrostomy (PEG) and intragastric feeding in TBI patients to assess safety and effectiveness. Methods: All patients on a TBI clinical pathway at our institution were targeted for early PEG. After PEG, standard enteral nutrition was initiated. Abdominal examination and gastric residual volumes were used to assess tolerance. Results: There were 118 patients with moderate to severe TBI. The average age was 36 years. Mean Injury Severity Score (ISS) was 25. Enteral access was obtained and intragastric feeding was initiated on day 3.6. Intragastric feeding was tolerated without complication in 111 of 114 (97%) patients. Five patients aspirated, but had no evidence of intolerance prior to the event. Conclusions: PEG provided reliable enteral access in moderate to severe TBI patients. Intragastric feeding was well tolerated with a low complication rate (4%). Copyright (C) 2000 Excerpta Medica Inc.  [References: 27]

155.    Kimberlin, D. W., & Malis, D. J. (2000). Juvenile onset recurrent respiratory papillomatosis: Possibilities for successful antiviral therapy. Antiviral Research, 45(2), 83-93.
Abstract: Recurrent respiratory papillomatosis (RRP) is a potentially devastating disease that can have significant morbidity, and can even result in mortality due to airway compromise or, less commonly, malignant transformation. Two distinct types of RRP exist: adult-onset RRP (AO-RRP) and juvenile-onset RRP (JO-RRP). Acquisition of human papillomavirus (HPV), the causative agent of RRP, is believed to occur in the peripartum period in the case of JO-RRP, with disease symptoms (primarily hoarseness) becoming apparent during the first several years of life. Treatment currently consists of surgical debulking of the papillomas to relieve airway obstruction. However, numerous antiviral therapies have also been evaluated, albeit primarily under uncontrolled settings. This article will review the biology, natural history and management of HPV infection, with particular emphasis on JO-RRP. Copyright (C) 2000 Elsevier Science B.V.  [References: 83]

156.    Johnson, J. A. (2000). Journal of Healthcare Management: Editorial. Journal of Healthcare Management, 45(3), 141.

157.    Jano, S., & Harlin, S. A. (2000). Designing a carotid endarterectomy critical pathway for your organization. Military Medicine, 165(5), 385-389.
Abstract: Background: Carotid endarterectomy (CEA) is one of the top-five surgical diagnosis-related groups at Keesler Medical Center. The geometric mean length of stay for CEA during fiscal year (FY) 1996 was 5.84 days (N = 41), compared with 1.79 for a benchmark facility. Objective: Create a critical pathway to standardize care, maintain/improve patient outcomes, reduce lengths of stay, and decrease costs. Methods: A multidisciplinary team was formed to evaluate four patient-flow options. The team decided to discharge patients directly from the intensive care unit to meet both patient and staff needs. Results: The geometric mean length of stay decreased to 1.70 days (N = 54) in FY 1998, compared with 2.42 days (N = 40) in FY 1997. The cost savings was $5,841 per case, compared with $1,684 before creation of the pathway. This represents an annual savings of more than $224,000 and a 30% reduction in length of stay. Conclusions: The CEA pathway has standardized the care received by this group of patients. By decreasing variation, processes have become routine and more efficient.  [References: 11]

158.    Insler, H., Stuchin, S. A., Kirschenbaum, I., & Perra, J. H. (2000). Development of orthopaedic critical pathways. Instr Course Lect, 49, 643-8.

159.    Hall, J. E. (2000). Establishing an integrated care pathway within an organic inpatient assessment service. Cpd Bulletin Old Age Psychiatry, 2(1), 3-6.
Abstract: Pathway implementation is an innovative response to demands common to many healthcare settings striving to improve efficiency without compromising quality. It can meet the requirements of local agendas and national directives by setting and monitoring multi-professional team standards of care. Originating in North America with increasing interest in the UK, application in mental health and elderly care remains rare. This paper describes the implementation of an integrated care pathway (ICP) within a NHS old age psychiatry inpatient organic assessment service. Effectiveness is assessed through comparative audit, variance analysis and a qualitative study of multidisciplinary impressions. The experience of this team is that the ICP has demonstrated professional, organisational and patient associated benefits, positively influencing clinical practice in dementia care.  [References: 7]

160.    Hall, G. F., Chu, B., Lee, G., & Yao, J. (2000). Human tau filaments induce microtubule and synapse loss in an in vivo model of neurofibrillary degenerative disease. Journal of Cell Science, 113(8), 1373-1387.
Abstract: The intracellular accumulation of tau protein and its aggregation into filamentous deposits is the intracellular hallmark of neurofibrillary degenerative diseases such as Alzheimer's Disease and familial tauopathies in which tau is now thought to play a critical pathogenic role. Until very recently, the lack of a cellular model in which human tau filaments can be experimentally generated has prevented direct investigation of the causes and consequences of tau filament formation in vivo. In this study, we show that human tau filaments formed in lamprey central neurons (ABCs) that chronically overexpress human tau resemble the 'straight filaments' seen in Alzheimer's Disease and other neurofibrillary conditions, and are distinguishable from neurofilaments by their ultrastructure, distribution and intracellular behavior. We also show that tau filament formation in ABCs is associated with a distinctive pattern of dendritic degeneration that closely resembles the cytopathology of human neurofibrillary degenerative disease. This pattern includes localized cytoskeletal disruption and aggregation of membranous organelles, distal dendritic beading, and the progressive loss of dendritic microtubules and synapses. These results suggest that tau filament formation may be responsible for many key cytopathological features of neurofibrillary degeneration, possibly via the loss of microtubule based intracellular transport.  [References: 71]

161.    Ferguson, R. P., Matz, R., Holmboe, E. S., & Krumholz, H. M. (2000). Use of critical pathways to improve the care of patients with acute myocardial infarction (multiple letters) [3]. American Journal of Medicine, 108(5), 433.

162.    Cameron, I., Crotty, M., Currie, C., Finnegan, T., Gillespie, L., Gillespie, W., Handoll, H., Kurrle, S., Madhok, R., Murray, G., Quinn, K., & Torgerson, D. (2000). Geriatric rehabilitation following fractures in older people: A systematic review. Health Technology Assessment (Rockville, Md), 4(2), i-iii+1-102.
Abstract: Background: The prevalence of fractures in older people is increasing rapidly. Different types of programmes are available for rehabilitation after these fractures. However, the effectiveness of these programmes is uncertain. Objectives: These were to identify, critically appraise and synthesise the published evidence for the effectiveness and cost-effectiveness of programmes of care following the acute management of fractures in older people. The principal focus is on rehabilitative care after proximal femoral fracture. Methods: Data sources: Electronic searching of MEDLINE, EMBASE and CINAHL databases. Search of bibliographies of all electronically identified studies. Search of databases of group members. Personal communication with experts in the field. Study selection: The inclusion criteria for the review were any systematic review or randomised, quasi-randomised or controlled cohort study reporting the outcome of a programme designed to improve function or reduce hospital stay in older people who have sustained a fragility/fall associated fracture in the lower limbs, pelvis, upper limbs or spine. Economic evaluations of studies meeting the inclusion criteria were also eligible. Published audit data from the UK in the last 5 years were examined to provide an indication of current treatment and outcome. Data extraction: Included studies were each sent to two reviewers for methodological appraisal and data extraction. Where reviewers differed on any item, each was asked to reconsider their decision. The two principal reviewers working together compiled the quality scores and data derived from each individual study. A nine-item methodological quality score was derived for each included study. Data synthesis: Individual studies were grouped by the type of intervention programme into seven categories defined by the two principal reviewers. Where similarity of interventions and outcomes allowed, the data were pooled using the Cochrane Collaboration Review Manager software. Results: Forty-one comparative studies (of which 14 were randomised trials) and seven audit studies were included. The comparative studies were classified into seven groups on the basis of the experimental intervention being investigated: (1) geriatric orthopaedic rehabilitation unit (GORU) - seven studies (2) geriatric hip fracture programme (GHFP) - five studies (3) early supported discharge (ESD) programme - six studies (4) introduction of clinical pathways for treatment of hip fracture - three studies (5) impact of the introduction of prospective payment systems (PPSs) - six studies (6) miscellaneous hospital programmes - four studies (7) specific types of therapy, nursing or medical care - 10 studies. These studies were heterogeneous. Striking variation was found in the reporting of outcomes, the details of the 'control' interventions, and the case mix; this limited pooling of data. The very limited data that were available suggest that: (1) GHFP, ESD and clinical pathways reduce total length of stay in hospital (2) there is no evidence that length of stay in a GORU is less than in a conventional orthopaedic unit (3) length of stay may be reduced by the introduction of a PPS (4) readmission rate after ESD shows a statistically non-significant increase (5) significantly higher rates of return to previous residential status are achieved by GHFP and by ESD (6) PPSs have led to increased use of nursing homes in the USA (7) there is no evidence that any of the programmes evaluated, nor the introduction of PPSs, are associated with changes in mortality (8) there are insufficient data to assess the impact of any programme on level of function, morbidity, quality of life or impact on carers (9) from a health and social services perspective, GHFP and ESD are likely to be cost-saving. The economic implications of GORU are less clear. Cost-saving associated with these programmes is achieved largely through the increased rate of return to previous residential status. Conclusions: Geriatric service interventions after hip fracture are complex: their form and outcomes are strongly influenced by local conditions. Comparative studies comparing different treatments and strategies are of poor to moderate quality, allowing only tentative conclusions. As an overall strategy for rehabilitation after hip and other lower limb fractures, GORUs are unlikely to be cost-effective, but some frailer patients may benefit in respect of reduced readmission rates and need for nursing home placement. GHFPs and ESD are probably cost-effective, since they appear to shorten the average length of hospital stay, and are associated with significantly increased rates of return to previous residential status. These programmes are not mutually exclusive; an optimal GHFP is likely to involve several elements. As ESD is suitable only for a subset of less disabled patients, an alternative programme for more disabled patients is needed; this is likely to require transfer following surgery, initially to an inpatient setting which might be provided in a GORU or a mixed assessment and rehabilitation unit (MARU). No direct comparison of GORUs and MARUs has been published. Both comparisons of packages of care (such as the GORU or MARU) and comparison of individual elements in these packages may require further research. The adoption of an agreed outcome data set for audit and research would be justified. Implications for practice: The authors consider that: (1) ESD should be a component of GHFPs to maximise opportunities for suitable individuals to return to their own homes as soon as possible. (2) New GORUs should not be established unless their superiority over mixed assessment and rehabilitation units (MARUs) is demonstrated. However, acute units managing hip fractures should retain access to assessment and rehabilitation services in GORUs or MARUs for the more disabled but previously community-dwelling patients. (3) There are insufficient data to recommend the introduction of formal clinical pathways in association with these practices, although there is weak evidence that they may be advantageous. Recommendations for research: (1) A study comparing the outcome of transfer of people previously living in the community unsuitable for ESD to a GORU or to a MARU should be considered. Given the paucity of cost-effectiveness information to date, this should include an economic evaluation. (2) Further studies of ESD and GHFPs to establish the evidence for best practice should be conducted. These should include evaluation of individual elements of care packages. Particular attention to methodological quality is required. (3) The adoption of an agreed outcome data set for research into and audit of rehabilitation after lower limb fractures in the elderly should be a priority, ideally before any new trials or new audit programmes are funded. Such a data set should include assessment of function, health-related quality of life, carer burden, and information allowing an economic analysis that takes a societal perspective and establishes the costs and savings of different models of care in relation to primary care services. (4) Adopted data sets/frameworks should be reviewed at least every 5 years.  [References: 87]

163.    Board, N., Brennan, N., & Caplan, G. (2000). Use of pathology services in re-engineered clinical pathways. Journal of Quality in Clinical Practice, 20(1), 24-29.
Abstract: A significant proportion of pathology tests ordered in hospital are unnecessary. Specific measures targeting the increasing appropriateness of pathology service use have been shown to decrease overall ordering of laboratory tests. However, it is not clear whether general programmes to improve quality of care will have any impact on the use of pathology services. Use of pathology services was compared within two separate prospective controlled clinical trials of re-engineered clinical pathways for both elective (surgical) patients and acute unplanned (medical) admissions. Trial One was a controlled trial of a re-engineered surgical service. Booked patients in the treatment group were admitted on the day of surgery, care was guided by a clinical pathway, and patients were discharged early with domiciliary post-acute care. Controls were admitted on the day before surgery, treated according to usual practice and discharged according to surgeons' preferences. In Trial Two, acute medical patients admitted to hospital through the Emergency Department (ED) were randomised into a treatment (Hospital in the Home) or a control (inpatient) care pathway. In both studies, patients on the re-engineered clinical pathways were well matched demographically and clinically. Health outcomes and satisfaction ratings were comparable. Seventy per cent fewer laboratory tests were ordered in the elective surgery intervention group (P < 0.0001), while the treatment group of the acute medical patients had 25% fewer tests ordered (P = 0.0133). Pooled results also showed a significantly lower rate of test ordering (P < 0.001) for the treatment group (Mann-Whitney U-Wilcoxon ranked sum test). The findings of these audits of controlled, prospective trials suggested overuse of laboratory tests in New South Wales public hospitals, and that savings can be generated by using clinical pathways and applying clinical criteria to the ordering of tests without adversely affecting health outcomes.  [References: 15]

164.    Bakal, C. W. (2000). Quality improvement for diagnostic neuroangiography and other procedures. Journal of Vascular & Interventional Radiology, 11(1), 1-3.

165.    Anonymous. (2000). CHF pathway increases ACE inhibitor prescribing. Hospital Formulary, 35(2), 185-189.

166.    Bates, D. W. (1999). Using information systems to improve practice. Schweizerische Medizinische Wochenschrift. Journal Suisse De Medecine, 129(49), 1913-9.
Abstract: Information systems are becoming a key tool for improving and measuring practice. They can improve care by providing decision support during routine care, by making important information more readily accessible, by pointing out redundancies, by suggesting alternatives, and by making guidelines accessible. Key domains, which are particularly amenable to such decision support, include drug prescribing, test ordering and implementation of critical pathways. In addition to their role in quality improvement, information systems can accomplish most quality measurement if key data are captured in coded form during the provision of routine care. These changes can help close the gap between knowledge and practice and promise to make the practice of evidence-based medicine a reality.

167.    Seale, G. S., & Abreu, B. C. (1999-2000). Pathways to better care. Rehab Management: The Interdisciplinary Journal of Rehabilitation, 12(1), 56, 58-59.
Abstract: Critical pathways lead neurorehabiliation to positive outcomes.   (4 ref)

168.    Teichgraber, U. K., Benter, T., Kluhs, L., Schroder, R. J., Hidajat, N., Dorken, B., & Felix, R. (1999). [Project graph technique for time management in abdominal ultrasound evaluations (see comments)]. Ultraschall in Der Medizin, 20(6), 236-41.
Notes: Comments: Comment in: Ultraschall Med 1999 Dec;20(6):224-5
Abstract: PURPOSE: German insurance companies are cutting down the time required for ultrasound examinations. To determine the minimal examination time to perform an ultrasound examination a project graph technique was applied. MATERIALS AND METHODS: Time measurements of abdominal ultrasound examinations were performed by two independent observers. The different jobs for the performance of an ultrasound examination were determined and the critical pathway method applied. The total available time for abdominal ultrasound examinations (leeway) was determined, the minimal time to perform each job was measured and the critical time required for the procedure was calculated. RESULTS: 14 different jobs were identified to complete one abdominal ultrasound examination. The project graph displayed the shortest possible time of 24 minutes to perform an ultrasound examination. The pure ultrasound exam without colour Doppler examination was 6 minutes ("hands on the ultrasound probe"). The jobs performed by the physician were fully within the critical period. In consequence, the physician had no leeway or time lag in relation to a total time of 24 minutes for an ultrasound examination, whereas by contrast the nurse has a total leeway of 7.5 minutes. CONCLUSIONS: The applied project graph technique is an effective instrument for the purpose of quality management for hospitals as well as in private practice. The workflow and actions necessary to perform a treatment or examination can be analysed. Human resources management and cost planning should be performed on the basis of project graphs.

169.    Schwoebel, A., & Jones, M. L. (1999). A clinical pathway system for the neonatal intensive care nursery. Journal of Perinatal & Neonatal Nursing, 13(3), 60-9.
Abstract: Health care reform, managed care, and the current outcomes movement have generated a rapid acceleration toward the development and implementation of clinical pathways in the field of neonatology. This article describes the design, implementation, and evaluation of an interdisciplinary clinical pathway system for a neonatal intensive care nursery. This neonatal clinical pathway is a clinical tool that delineates practice guidelines for each discipline that provides care to a specific infant population. It has reduced variation in clinical process and thereby has been shown to improve the quality of infant care. When practice guidelines and documentation are linked to health and economic outcomes, they begin to significantly impact health care costs.

170.    Nunez Mora, C., Rios Gonzalez, E., Chamorro Ramos, L., De Cabo Ripoll, M., Tabernero Gomez, A., Martinez-Pineiro Lorenzo, L., Cisneros Ledo, J., Garcia Caballero J, & de la Pena Barthel, J. J. (1999). [Development of a clinical pathway for radical prostatectomy]. Archivos Espanoles De Urologia, 52(10), 1051-9.
Abstract: OBJECTIVE: To describe the clinical care path for retropubic radical prostatectomy of the La Paz teaching hospital and the results achieved after the first 6 months. METHODS: We have developed a clinical care path for radical prostatectomy with a hospital stay of 6 days. Thirty-one patients submitted to retropubic radical prostatectomy from June to November 1998 were included in the program. The mean length of total, preoperative and postoperative stay were analyzed and compared with those of 31 patients who had undergone radical prostatectomy before the program was developed. Readmissions, adverse effects and patient satisfaction were also analyzed. RESULTS: Of the 31 patients included in the clinical care path, 22 (71%) had a stay equal to or less than the program's length of stay. The mean total, pre and postoperative stay for the group of patients included in the clinical care path were 6.0 days (SD = 1.1), 1 day (SD = 0.0) and 4.9 days (SD = 1.1), respectively. The length of stay was significantly longer before the program was developed [mean total 10.2 days (SD = 4.9), mean preoperative 2.6 days (SD = 2.6) and mean postoperative 7.6 days (SD = 3.6)] (p < 0.001). Twenty-four patients (77.4%) completed the questionnaire on patient satisfaction, which was highly positive, the overall patient satisfaction rate being higher than the 90% standard. There were no readmissions or significant events ascribable to the program. CONCLUSIONS: In our experience, the clinical care path for radical prostatectomy is a useful tool to reduce the unwanted variability. Its design is based on the best possible evidence, therefore the scientific and technical quality, patient satisfaction and efficiency are enhanced. In our view, our results are attainable and feasible in any health care setting.

171.    Norris, A. C., & Briggs, J. S. (1999). Care pathways and the information for health strategy. Health Informatics Journal, 5(4), 209-12.
Abstract: The paper first defines integrated care pathways (ICPs) and demonstrates the important role for ICPs revealed by the NHS 'Information for Health' (IfH) strategy and related documents. Following a review of the main features of ICPs, the paper continues by considering their status in the UK and how their profile is raised by the IfH document. This discussion explores the relationship of ICPs to electronic patient records, seamless care, and the quality initiatives raised by the organizational changes broadcast in the White Paper, 'The New NHS'. The paper then summarizes the main reasons for the limited uptake of ICPs and suggests that the clinical and cultural barriers could be more readily overcome if the production of electronic, computerized ICPs were more facile. It concludes by advancing a simple model for electronic ICP production and offers a hierarchical approach to incremental design and development.   (16 ref)

172.    Motwani, J., Klein, D., & Navitskas, S. (1999). Striving toward continuous quality improvement: a case study of Saint Mary's Hospital. Health Care Manag, 18(2), 33-40.
Abstract: This case analysis is the result of a year-long study designed to identify and assess the ingredients that led to the successful implementation of a continuous quality improvement (CQI) program at Saint Mary's Hospital in Grand Rapids, Michigan. The key ingredients of success included: (1) an organizational structure and leadership commitment for identifying and improving processes, (2) use of data-based statistical and analytical tools to study processes, (3) empowerment of teams of employees to take charge of the operations of their own work tasks in a manner that encourages continuous learning, (4) involvement of internal and external customers through the improvement process, and (5) development of effective measures for monitoring improvement. The benefits of the CQI efforts at Saint Mary's have been remarkable and hospital-wide.

173.    Kight, L. (1999). Critical path network. Chest pain rule-out MI clinical pathway saves $183,000. Hospital Case Management, 7(12), 207-210.

174.    Jones, M. L., Day, S., Creely, J., Woodland, M. B., & Gerdes, J. B. (1999). Implementation of a clinical pathway system in maternal newborn care: a comprehensive documentation system for outcomes management. Journal of Perinatal & Neonatal Nursing, 13(3), 1-20.
Abstract: This article describes the design, implementation, and evaluation of an interdisciplinary clinical pathway system for maternal newborn care in a perinatal regional referral institution. Core issues in the design of this system are addressed to promote outcomes management and ongoing performance improvement. A discussion of the implementation follows, illustrating the lessons learned, changes made, and associated evaluation. This clinical pathway system has improved communication and collaboration among all disciplines, enhanced the discharge coordination process, and established protocols available to all members of the health care team.

175.    Husbands, J. M., Weber, R. S., Karpati, R. L., Weinstein, G. S., Chalian, A. A., Goldberg, A. N., Thaler, E. R., & Wolf, P. F. (1999). Clinical care pathways: decreasing resource utilization in head and neck surgical patients. Otolaryngology - Head & Neck Surgery, 121(6), 755-9.
Abstract: In this era of decreasing reimbursement, health systems have been forced to become more efficient and decrease resource utilization to remain financially viable. One of the methods of internal cost control has been the use of clinical pathways. Given the complexity of treatment of head and neck cancer patients, clinical pathways can help to standardize decision making and introduce uniformity in resource utilization. The objective of this study is to compare resource utilization and outcomes before and after implementation of a clinical pathway for head and neck surgical patients. We observed significant decreases in hospital costs as well as shorter lengths of stay after pathway implementation. It is our belief that a uniform management tool is beneficial in this complex disease.

176.    Hahn, J. (1999). Walking the pathway to outcome measurement. Home Health Care Management & Practice, 12(1), 36-41.
Abstract: The pairing of a clinical pathway with an outcome measurement tool provides the home care agency not only with the analysis to redefine "best practice" standards for patient populations but also with a concept of cost containment. In today's health care market place of limited dollars, the consistent ongoing measurement of care delivery provides the data to confirm program effectiveness while demonstrating quality care, cost savings, and positive care outcomes for payors, physicians, referral sources, and patients. Copyright &#169; 1999 by Aspen Publishers, Inc.   (3 ref)

177.    Ellstrom, K. E. (1999). Breathing easier in the intensive care unit. Pneumonia. Crit Care Nurs Clin North Am, 11(4), 409-22.
Abstract: Pneumonia, whether it is community-acquired, hospital-acquired, or ventilator-acquired, has a high incidence with associated high morbidity and mortality. The continuing emergence of resistant organisms is an indication that appropriate measures are still not effective or are not being used effectively to control the incidence of HAP and VAP as well as evidence of the overuse of antibiotics. Nurses are key in identifying patients at risk and instituting preventive measures. Continuing issues are the use of an adequate handwashing technique and elevation of the head of the bed for prevention of HAP and VAP and immunization of all patients at risk for CAP. Effective interventions can be evaluated by following best practices, using quality and process improvement methodology, and measuring appropriate outcomes.

178.    Eisenberg, A. A., & Redick, E. L. (1999). Caring for a patient after resection of pituitary adenoma. Nursing, 29(12 Crit Care), 32cc1-2, 32cc4-6.
Abstract: Using a clinical pathway can help you anticipate complications and improve patient outcomes.   (3 ref)

179.    Dykes, P. C., & Cain, G. (1999). Measuring outcomes in outpatient settings. How one company is using clinical pathways for depression. Behav Healthc Tomorrow, 8(6), 23-6.

180.    Burns, S. M. (1999). Making weaning easier: pathways and protocols that work. Critical Care Nursing Clinics of North America, 11(4), 465-79.
Abstract: Weaning patients from prolonged ventilation can be difficult, time-consuming, and costly. As a result, institutions, as well as the clinicians who are charged with the care of patients, struggle to determine quality solutions. Increasingly, critical pathways and weaning protocols are being used to accomplish this goal. This article describes the science related to the use of pathways and protocols for longterm mechanically ventilated patients and how they may be applied clinically to attain quality outcomes. Copyright (c) 1999 by W.B. Saunders Company   (51 ref)

181.    Benenson, R., Magalski, A., Cavanaugh, S., & Williams, E. (1999). Effects of a pneumonia clinical pathway on time to antibiotic treatment, length of stay, and mortality. Academic Emergency Medicine, 6(12), 1243-8.
Abstract: OBJECTIVES: A clinical pathway standardizing management for patients with an admission diagnosis of pneumonia was initiated after a previous study found delayed time to initial antibiotic administration, a longer length of stay, and higher mortality rate for the authors' patients as compared with those in a "benchmark" hospital. The current study was undertaken to determine whether implementation of the clinical pathway resulted in statistically significant decreases for these measures, both in the initial year following pathway implementation and two years later. METHODS: A retrospective chart review was completed for three cohorts of pneumonia patients admitted via the ED: 1) three months immediately prior to pathway implementation, 2) 10-12 months after implementation of the pathway, and 3) 34-36 months after implementation of the pathway. Four standard antibiotic regimens were used following pathway implementation: community-acquired, community-acquired penicillin-allergic, nursing home-acquired, and nursing home-acquired penicillin-allergic. Demographics, medical history, presentation signs and symptoms, process of care, and outcome data were abstracted from each patient's medical record. RESULTS: The mean time to antibiotic administration decreased from 315 minutes prepathway to approximately 175 minutes during the first postpathway period and 171 minutes at three years (ANOVA, p < 0.0001). The percentage of patients who received antibiotics in the ED increased from 58% prepathway to 94% during the first postpathway period and 97% at three years (chi square, p < 0.0001). Length of stay decreased from 9.7 prepathway to 8.9 days during the first postpathway period and 6.4 days at three years (ANOVA, p < 0.0001). There was no significant change of in-hospital mortality (9.6% prepathway to 5.2% and 4.9%) in the two respective periods. CONCLUSIONS: This study demonstrates that implementation of a pneumonia clinical pathway for the management of hospitalized patients admitted via the ED decreases the time to initial antibiotic treatment and increases the proportion of patients initially treated with antibiotics in the ED. These effects were evident in the first year following pathway implementation and sustained at the three-year study interval.

182.    Anonymous. (1999). Practice Resource Network: frequently asked questions. Defining the differences in clinical practice guidelines. AACN News, 16(12), 4.

183.    Jones, A. (1999). Mental health. The development of mental health care pathways: friend or foe? British Journal of Nursing, 8(21), 1441-3.
Abstract: Greater emphasis is being placed on mental health services to be more responsive to clinical variation. Care pathways can standardize clinician response to established diagnostic groups such as schizophrenia. This article disusses care pathways using the findings of a research study carried out in London to explore the development and implementation of a care pathway. Respondents encountered many difficulties such as the principles behind individualized care and generic roles and responsibilities in preformulating their work into a care pathway sequence. This article concludes with areas for further application and research.   (14 ref)

184.    Walsh, M. (1999). The life-savers. Nursing Times, 95(44), 24-6.
Abstract: At the start of our series of case studies in A&E nursing and follow-on care, Mike Walsh gives an overview of the importance of multidisciplinary teamwork in caring for trauma patients.   (1 ref)

185.    Rosenstein, A. H. (1999). Measuring the benefit of performance improvement and decision support. American Journal of Medical Quality, 14(6), 262-9.
Abstract: In an effort to provide high quality care in a more cost-effective manner, health care providers have found it necessary to implement a series of decision support strategies designed to improve outcomes of care. While each of these strategies has measurable benefits, each comes along with additional costs. As more and more technology becomes available and more labor resources are devoted to these efforts, it becomes crucial to be able to assess the costs and benefits of these programs. A return-on-investment methodology is used to assess the financial impact of service-related operating expenses compared to revenue gains from service delivery. However, unlike traditional return-on-investment models, in health care, benefits are frequently gained from cost avoidance rather than from revenue enhancement activities. This article will describe a methodology for measuring the direct and indirect costs and qualitative and quantitative benefits of decision support activities.

186.    Haynie, L., & Garrett, B. (1999). Developing a customer-service and cost-effectiveness team. Journal for Healthcare Quality: Promoting Excellence in Healthcare, 21(6), 28-29, 32-34.

187.    Cunningham, A. J. (1999). Anesthetic implications of laparoscopic surgery. Yale Journal of Biology & Medicine, 71(6), 551-78.
Abstract: Minimally invasive therapy aims to minimize the trauma of any interventional process but still achieve a satisfactory therapeutic result. The development of "critical pathways," rapid mobilization and early feeding have contributed towards the goal of shorter hospital stay. This concept has been extended to include laparoscopic cholecystectomy and hernia repair. Reports have been published confirming the safety of same day discharge for the majority of patients. However, we would caution against overenthusiastic ambulatory laparoscopic cholecystectomy on the rational but unproven assumption that early discharge will lead to occasional delays in diagnosis and management of postoperative complications. Intraoperative complications of laparoscopic surgery are mostly due to traumatic injuries sustained during blind trocar insertion and physiologic changes associated with patient positioning and pneumoperitoneum creation. General anesthesia and controlled ventilation comprise the accepted anesthetic technique to reduce the increase in PaCO2. Investigators have recently documented the cardiorespiratory compromise associated with upper abdominal laparoscopic surgery, and particular emphasis is placed on careful perioperative monitoring of ASA III-IV patients during insufflation. Setting limits on the inflationary pressure is advised in these patients. Anesthesiologists must maintain a high index of suspicion for complications such as gas embolism, extraperitoneal insufflation and surgical emphysema, pneumothorax and pneumomediastinum. Postoperative nausea and vomiting are among the most common and distressing symptoms after laparoscopic surgery. A highly potent and selective 5-HT3 receptor antagonist, ondansetron, has proven to be an effective oral and IV prophylaxis against postoperative emesis in preliminary studies. Opioids remain an important component of the anesthesia technique, although the introduction of newer potent NSAIDs may diminish their use. A preoperative multimodal analgesic regimen involving skin infiltration with local anesthesia. NSAIDs to attenuate peripheral pain and opioids for central pain may reduce postoperative discomfort and expedite patient recovery/discharge. There is no conclusive evidence to demonstrate clinically significant effects of nitrous oxide on surgical conditions during laparoscopic cholecystectomy or on the incidence of postoperative emesis. Laparoscopic cholecystectomy has proven to be a major advance in the treatment of patients with symptomatic gallbladder disease. [References: 152]

188.    Coleman, J. R. (1999). Integrated case management: the 21st century challenge for HMO case managers, Part II. Case Manager, 10(6), 28-33.

189.    Skolnick, B. E. (1999). Guidelines for acute stroke treatment centers. Physical Medicine & Rehabilitation Clinics of North America, 10 (4), 801-13, viii.
Abstract: This article provides a description of the clinical infrastructure of a stroke center, including staffing requirements, technical capabilities, and recommended clinical protocols. These recommendations have been developed to assist in establishing new acute stroke centers that can deliver quality care and to aid in evaluating the relative strengths and weaknesses of existing stroke centers. [References: 35]

190.    Rymer, M. M., Summers, D., & Soper, P. (1999). Development of clinical pathways for stroke management: an example from Saint Luke's Hospital, Kansas City. Clinics in Geriatric Medicine, 15(4), 741-64.
Abstract: Clinical pathways for stroke are important tools for improved case management and outcome assessment. The clinical path created at St. Luke's Hospital in Kansas City is described here. It evolved through the collaboration of a multidisciplinary team of clinical experts and is still evolving. Ideally, a clinical path should be used as a guide rather than a standard of care, which is to be individualized for each patient. This article describes the methods for writing the pathways and how they are used for documentation. It also summarizes how the pathway data support stroke outcome assessment.

191.    Pritts, T. A., Nussbaum, M. S., Flesch, L. V., Fegelman, E. J., Parikh, A. A., & Fischer, J. E. (1999). Implementation of a clinical pathway decreases length of stay and cost for bowel resection. Annals of Surgery, 230(5), 728-33.
Abstract: OBJECTIVE: To examine the effect of a clinical pathway for small and large bowel resection on cost and length of hospital stay. SUMMARY BACKGROUND DATA: Clinical pathways are designed to streamline patient care delivery and maximize efficiency while minimizing cost. Theoretically, they should be most effective in commonly performed procedures, in which volume and familiarity are high. METHODS: A clinical pathway to assist in the management of patients undergoing bowel resection was developed by a multidisciplinary team and implemented. Data about length of stay and cost was collected for all patients undergoing bowel resection 1 year before and 1 year after pathway implementation. Three groups were compared: patients undergoing bowel resection in the year prior to pathway implementation (prepathway), patients in the year after pathway implementation but not included on the pathway (nonpathway), and patients included in the pathway (pathway). RESULTS: The mean cost per hospital stay was $19,997.35 +/- 1244.61 for patients in the prepathway group, $20,835.28 +/- 2286.26 for those in the nonpathway group, and $13,908.53 +/- 1113.01 for those in the pathway group (p < 0.05 vs. other groups). Mean postoperative length of stay was 9.98 +/- 0.62 days (prepathway), 9.68 +/- 0.88 days for (nonpathway), and 7.71 +/- 0.37 days (pathway) (p < 0.05 vs. other groups). CONCLUSIONS: Implementation of the pathway produced significant decreases in length of stay and cost in the pathway group as compared to the prepathway group. These results support the further development of clinical pathways for general surgical procedures.

192.    Noetscher, C. M. (1999). Using data in the case management process. Journal of Nursing Care Quality, (Spec Issue 1), 86-97.
Abstract: This article describes the role of the case manager in improving hospital utilization and outcomes. It suggests a number of indicators for measurement of quality and resource use based on extensive experience with the case management process. It also provides guidance concerning the development and use of these indicators within acute care organizations. It provides information concerning specific situations encountered by case managers. Copyright &#169; 1999 by Aspen Publishers, Inc.   (9 ref 7 bib)

193.    Mathias, J. M. (1999). Teamwork is pathway to the top. Or-Manager, 15(11), 26,28.

194.    Jones, A. (1999). A modernized mental health service: the role of care pathways. Journal of Nursing Management, 7(6), 331-8.
Abstract: Aim: This paper reviews the impact of the UK governments' strategy and structures to improve the quality of mental health care. The possible role of care pathways within this modernization agenda is discussed. Background: The governments' emphasis upon reducing clinical variation and cost effective treatments complements both the historical and structural elements of care pathways. This paper is a reflection on some of the issues within this debate. Methods: The paper reviews the latest publications from government sources and draws on the authors' research and critical analysis of the care pathway literature. Findings: The government has made an explicit movement towards structuring care processes within the newly formed National Service Framework. However, there are many problems in following standardized care processes such as professional antagonism and a relative dearth of evidence-based practice. Conclusion: Further research is required to examine the wider impact of government initiatives on the work force. Care pathways may provide the structure for this research and development activity.   (69 ref)

195.    Huang, F., Buttini, M., Wyss-Coray, T., McConlogue, L., Kodama, T., Pitas, R. E., & Mucke, L. (1999). Elimination of the class A scavenger receptor does not affect amyloid plaque formation or neurodegeneration in transgenic mice expressing human amyloid protein precursors. American Journal of Pathology, 155(5), 1741-7.
Abstract: The class A scavenger receptor (SR) is expressed on reactive microglia surrounding cerebral amyloid plaques in Alzheimer's disease (AD). Interactions between the SR and amyloid beta peptides (Abeta) in microglial cultures elicit phagocytosis of Abeta aggregates and release of neurotoxins. To assess the role of the SR in amyloid clearance and Abeta-associated neurodegeneration in vivo, we used the platelet-derived growth factor promoter to express human amyloid protein precursors (hAPPs) in neurons of transgenic mice. With increasing age, hAPP mice develop AD-like amyloid plaques. We bred heterozygous hAPP (hAPP(+/-)) mice that were wild type for SR (SR(+/+)) with SR knockout (SR(-/-)) mice. Crosses among the resulting hAPP(+/-)SR(+/-) offspring yielded hAPP(+/-) and hAPP(-/-) littermates that were SR(+/+) or SR(-/-). These second-generation mice were analyzed at 6 and 12 months of age for extent of cerebral amyloid deposition and loss of synaptophysin-immunoreactive presynaptic terminals. hAPP(-/-)SR(-/-) mice showed no lack of SR expression, plaque formation, or synaptic degeneration, indicating that lack of SR expression does not result in significant accumulation of endogenous amyloidogenic or neurotoxic factors. In hAPP(+/-) mice, ablation of SR expression did not alter number, extent, distribution, or age-dependent accumulation of plaques; nor did it affect synaptic degeneration. Our results do not support a critical pathogenic role for microglial SR expression in neurodegenerative alterations associated with cerebral beta amyloidosis.

196.    Hanna, E., Schultz, S., Doctor, D., Vural, E., Stern, S., & Suen, J. (1999). Development and implementation of a clinical pathway for patients undergoing total laryngectomy: impact on cost and quality of care. Archives of Otolaryngology -- Head & Neck Surgery, 125(11), 1247-51.
Abstract: BACKGROUND: The current health care climate demands the provision of quality patient care in a cost-effective manner. Clinical pathways define the essential components of care that are provided to patients with a specific diagnosis to achieve a desired outcome within a predetermined period. Development and implementation of clinical pathways streamline the provision of quality care in the most cost-effective manner. OBJECTIVES: To develop a clinical pathway for patients undergoing total laryngectomy and to evaluate its impact on the cost and quality of care provided to these patients. SETTING: A tertiary care academic medical center. PATIENTS AND METHODS: A total of 45 patients were included in the study. The clinical pathway was implemented for 15 patients, while the other 30 patients were treated without the implementation of the pathway guidelines. MAIN OUTCOME MEASURES: Length of hospital stay, readmission rate, and hospital variable costs. RESULTS: The clinical pathway affected all cost outcome measures. Length of stay decreased by 2.4 days (29%; P=.001), and the average hospital variable cost decreased from $3992 to $3419 per case. This represents a 14.4% reduction in cost associated with pathway implementation (P=.02). The standardization of care eliminated unnecessary variation and repetition in resource usage, resulting in overall cost reduction. Pathway implementation resulted in a lower readmission rate (7% [1/15]) than that of patients treated prior to protocol implementation (23% [7/30]). CONCLUSION: Implementing a carefully developed clinical pathway may reduce cost without compromising the quality of care for patients undergoing total laryngectomy.

197.    Foster, M. A., Ragsdale, K., Dunne, B., Jones, E., Ihnen, G. H., Lentz, C., & Gilmore, J. (1999). Detection and treatment of depression in a VA primary care clinic. Psychiatric Services, 50(11), 1494-5.
Abstract: The Veterans Health Administration clinical guideline for major depressive disorder was used in screening 574 male veterans treated in primary care settings in the Department of Veterans Affairs health care system. Thirteen percent (N=73) screened positive for depression, and 33 percent of those patients showed evidence of a major depressive episode. Pre- and posttreatment assessment of a sample of 16 patients treated for depression in a primary care setting revealed statistically significant improvement with treatment.

198.    Cannon, C. P. (1999). Diagnosis and management of patients with unstable angina. Current Problems in Cardiology, 24(11), 681-744.

199.    Birmingham, J. (1999). Care along the continuum. Transfer DRGs as a continuum management affair. Curtincalls, 1(12), 9.

200.    Anonymous. (1999). CRITICAL PATH NETWORK  DVT/PE path: specific, detailed, and effective. Hospital Case Management, 7(11), 191-194.

201.    Anderson, B., Higgins, L., & Rozmus, C. (1999). Critical pathways: application to selected patient outcomes following coronary artery bypass graft. Applied Nursing Research, 12(4), 168-74.
Abstract: As health care reform evolves in the United States, many hospitals are implementing strategies to contain the cost of coronary artery bypass graft (CABG) surgery. The purpose of this study was to examine the length of stay in the intensive care unit (ICU) after CABG surgery relative to the number of hours, postoperation, when ambulation occurred, and to examine the overall postoperative length of hospital stay. The study found a significant difference between ICU length of stay and the time when ambulation was initiated (t(150) = -2.68; p = .004). These results suggest that CABG patients with shorter ICU stays begin ambulation sooner, thus potentially reducing the risk of postoperative complications as well as cost. No other significant differences were demonstrated.

202.    Adcock, K. G., Akins, R. L., & Farrington, E. A. (1999). Evaluation of empiric vancomycin therapy in children with fever and neutropenia. Pharmacotherapy, 19(11), 1315-20.
Abstract: A retrospective evaluation was conducted to determine which children admitted for fever and neutropenia required empiric vancomycin therapy, and to develop a clinical pathway for appropriate treatment. Chart review identified 109 admissions of 36 pediatric oncology patients for fever and neutropenia, of which 88 were eligible for analysis. Blood cultures isolated 17 gram-positive organisms; coagulase-negative staphylococci and viridans group streptococci were cultured most frequently (82%). We concluded that previous high-dose cytarabine therapy, inflamed central access site, and hypotension or septic shock are possible indicators of febrile, neutropenic patients at high risk for gram-positive pathogen isolation. These predictors then were used to determine which children would receive empiric vancomycin therapy.

203.    Macnab, A. J., Susak, L., Gagnon, F. A., Alred, J., & Sun, C. (1999). The cost-benefit of pulse-oximeter use in the prehospital environment. Prehospital Disaster Med, 14(4), 245-50.
Abstract: INTRODUCTION: Pulse-oximetry has proven clinical value in Emergency Departments and Intensive Care Units. In the prehospital environment, oxygen is given routinely in many situations. It was hypothesized that the use of pulse oximeters in the prehospital setting would provide a measurable cost-benefit by reducing the amount of oxygen used. METHODS: This was a prospective study conducted at 12 ambulance stations (average transport times > 20 minutes). Standard care protocols and paramedic assessments were used to determine which patients received oxygen and the initial flow rate used. Pulse-oximetry measurements (SpO2) were then taken. If SpO2 fell below 92% or rose above 96% (except in patients with chest pain), oxygen (O2) flow rates were adjusted. Costs of oxygen use were calculated: volume that would have been used based on initial flow rate; and volume actually used based on actual flow rates and transport time. RESULTS: A total of 1,907 patients were recruited. Oximetry and complete data were obtained on 1,787 (94%). Of these, 1,329 (74%) received O2 by standard protocol: 389 (27.5%) had the O2 flow decreased; 52 had it discontinued. Eighty-seven patients (6%) not requiring O2 standard protocol were hypoxemic (SpO2 < 92%) by oximetry, and 71 patients (5%) receiving oxygen required flow rate increases. Overall, O2 consumption was reduced by 26% resulting in a cost-savings of $0.20/patient. Prehospital pulse-oximetry allows unnecessary or excessive oxygen therapy to be avoided in up to 55% of patients transported by ambulance and can help to identify suboptimally oxygenated patients (11%). CONCLUSIONS: Rationalizing the O2 administration using pulse-oximetry reduced O2 consumption. Other health care savings likely would result from a reduced incidence of suboptimal oxygenation. Oxygen cost-saving justifies oximeter purchase for each ambulance annually where patient volume exceeds 1,750, less frequently for lower call volumes, or in those services where the mean transport time is less than the 23 minute average noted in this study.

204.    Klingbell, K. S., & Nemeth, L. S. (1999). Tools and systems for improved outcomes. Defining outcomes statements for high-risk psychosocial patients. Outcomes Management for Nursing Practice, 3(4), 141-3.

205.    Klingbeil, K. S., & Nemeth, L. S. (1999). Defining outcome statements for high-risk psychosocial patients. Outcomes Manag Nurs Pract, 3(4), 141-3.

206.    Rohrbach, J. I. (1999). Critical pathways as an essential part of a disease management program. Journal of Nursing Care Quality, 14(1), 11-5.
Abstract: 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.

207.    Price, J., Ekleberry, A., Grover, A., Melendy, S., Baddam, K., McMahon, J., Villalba, M., Johnson, M., & Zervos, M. J. (1999). Evaluation of clinical practice guidelines on outcome of infection in patients in the surgical intensive care unit [see comments]. Critical Care Medicine, 27(10), 2118-24.
Notes: Comments: Comment in: Crit Care Med 1999 Oct;27(10):2290-1
Abstract: OBJECTIVE: In this study, clinical practice guidelines were developed by a multidisciplinary team for patients with infections admitted to a surgical intensive care unit (ICU). DESIGN: A 51-day baseline audit period (Phase I) in a 20-bed (private rooms) surgical ICU was compared with a 34-day period in the same unit after implementation of the guidelines (Phase II). PATIENTS: Phase I included 182 patients (670 patient days), and Phase II included 139 patients (427 patient days). RESULTS: There was no significant difference between patients in the Phase I and Phase II groups regarding age (65.4/19-95 vs. 64.8/18-90 yrs), gender (56% male vs. 55% male), severity of illness (mean Acute Physiology and Chronic Health Evaluation III, 38 vs. 39.1), total infections (respiratory, 8% vs. 4%; urinary tract, 15% vs. 4%; wound, 4% vs. 3%; skin/soft tissue, 3% vs. 7%; sepsis, 5% vs. 3%; intra-abdominal, 9% vs. 17%), and no infection (64% vs. 67%). Clinical outcomes of patients with infections in the Phase I group compared with those in the Phase II group were as follows: clinical improvement or cure, 64% vs. 76%; persistent infection, 17% vs. 11%; clinical failure, 0 vs. 2%; and death, 18% vs. 7% (p = NS). When patients with infections were compared, death rates were 20% in the Phase I group and 5.6% in the Phase II group (p = .02). After implementation of the clinical pathways, antibiotic costs were reduced from $676.54 per patient to $157.88 per patient (p = .001). Length of stay in the ICU was 3.7 days in the Phase I trial and a mean of 3 days in the Phase II trial (p = NS). Specimens of Escherichia coli demonstrated a trend toward a decreased resistance to all antibiotics and Pseudomonas aeruginosa to ciprofloxacin and aminoglycosides (p = NS). CONCLUSIONS: In this study, the use of clinical practice guidelines for patients who were admitted to the surgical ICU was shown to reduce costs, without adversely affecting patients' outcomes. This study has important implications for the use of clinical practice guidelines for the management of patients with infections who are admitted to surgical ICUs.

208.    Pitt, H. A., Murray, K. P., Bowman, H. M., Coleman, J., Gordon, T. A., Yeo, C. J., Lillemoe, K. D., & Cameron, J. L. (1999). Clinical pathway implementation improves outcomes for complex biliary surgery. Surgery, 126(4), 751-6; discussion 756-8.
Abstract: BACKGROUND: Complex biliary surgery is associated with significant morbidity, prolonged hospital stay, and high cost. Clinical pathway implementation has the potential to standardize treatment and improve outcomes. Therefore the aim of this analysis was to determine whether clinical pathway implementation and/or feedback of outcome data would alter hospital stay, charges, and mortality rates for complex biliary surgery at an academic medical center METHODS: Pre- and postoperative length of stay, hospital charges, and mortality rates were monitored for 36 months before (period 1) and for 2 18-month periods (periods 2 and 3) after implementation of a clinical pathway for hepaticojejunostomy. Outcome data were provided to the surgeons 18 months after pathway implementation to determine whether further clinical practice improvement was possible. RESULTS: From 1991 to 1997, 339 patients underwent hepaticojejunostomy at The Johns Hopkins Hospital for malignant and benign biliary obstruction. Total length of stay was 13.3 +/- 0.9 days for period 1 compared with 12.5 +/- 0.8 days for period 2 (not significant) and 10.1 +/- 0.3 days for period 3 (P < .01 vs period 1; P < .03 vs period 2). Hospital charges averaged $24,446 during period 1 compared with $23,338 during period 2 and $20,240 during period 3 (P < .01 vs periods 1 and 2). Hospital mortality rate was 4.5% during period 1 compared with 0.7% during periods 2 and 3 (P < .05). CONCLUSIONS: These data suggest that implementation of a clinical pathway for hepaticojejunostomy reduces hospital mortality rates and that feedback of outcome data to surgeons results in further clinical practice improvement. Thus clinical pathway implementation and feedback are effective methods to control costs at an academic medical center.

209.    Pearson, S. D. (1999). Et tu, critical pathways? [editorial; comment]. American Journal of Medicine, 107(4), 397-8.
Notes: Comments: Comment on: Am J Med 1999 Oct;107(4):324-31

210.    Menegoz, F., Exbrayat, C., Sousbie, M., Laforet, C., Colonna, M., Veran-Peyret, M. F., & Schaerer, R. (1999). [Patterns of health care delivery and breast cancer in the department of Isere in 1955]. Revue d Epidemiologie Et De Sante Publique, 47(5), 443-53.
Abstract: BACKGROUND: Caring for cancer patients is expensive, warranting verification that health care organization works in a satisfactory way. A first step of this evaluation deals with the description of the pathway followed in the health care system by the patient. METHODS: 671 breast cancer cases were diagnosed in Isere in 1995. According to the place where each treatment (surgery, chemotherapy, radiotherapy) was performed, we described pathways for the patient, either entirely private, public or mixed. Characteristics of the patient (age, place of residence), of the disease (extent of disease, way of discovery) and of the physician (general practitioner, specialist) might have influenced the choice of this pathway. We described and tested the distribution of these characteristics within the 3 groups using univariate analysis. Relative risk of being affected to the private pathway compared to the public one was computed, after adjusting for age, type of physician, extent of disease, way of discovery and sanitary area, using a multivariate analysis (logistic regression). RESULTS: In the department of Isere, the private pathway cared for 55% of breast cancers, the public one 23% and the mixed one 19%. There was no preferential recruitment according to age, physician type, presence of metastasis or of the rural or urban residence. In sanitary area number 5, characterized by an important attraction of the patients by the nearby department of Rhone, 41% of the patients were cared for the private pathway, compared to 63% in sanitary area 4, where most patients were treated in the main town of Isere: Grenoble. After early breast cancer detection with mammography instead of breast cancer screening, probability of being cared for in the private pathway was 2-fold higher (OR = 2) than in the public one. CONCLUSION: In Isere department, early breast cancer detection with mammography is in favor of the private pathway. This is not true for physician type, neither for characteristics of the patient or extent of the disease. Finally, the distance to next department of oncology or radiotherapy plays a major role.

211.    McKinsey, K. T., Boren, D. M., & Fidellow, J. A. (1999). Navigate a clinical pathway for uncomplicated MI patients. Nursing Management (Chicago), 30(10), 33-5.
Abstract: At Naval Medical Center San Diego, a clinical pathway for uncomplicated myocardial infarction patients decreased length of stay, standardized practice, and significantly improved documentation and discharge practices.   (2 ref)

212.    Kosnik, L. (1999). Treatment protocols and pathways: improving the process of care. Critical Care Nurse, (Suppl), 3-7, 16-17.

213.    Knox, D., & Mischke, L. (1999). Implementing a congestive heart failure disease management program to decrease length of stay and cost [see comments]. Journal of Cardiovascular Nursing, 14(1), 55-74.
Notes: Comments: Comment in: J Cardiovasc Nurs 1999 Oct;14(1):v-vii
Abstract: Congestive heart failure (CHF) is the most common reason for a hospital admission in the Medicare age group and is nearly double the rate of pneumonia, the next highest volume diagnosis. The economic burden of this debilitating, chronic disease demands a mechanism to improve quality of care while preventing unnecessary hospitalizations. Beginning in 1995, Evanston Northwestern Healthcare (ENH) created a disease management program involving a multidisciplinary team designed to decrease length of stay (national average = 6.2 days; ENH = 4 days), reduce costs, prevent readmissions (national 30-day readmission rate = 23%; ENH CHF Program = 2.3%), and improve compliance with the treatment regimen. Compliance monitoring through an automated telemanagement program reinforces education, identifies early warning signs and reduces the likelihood of hospitalization. After 18 months, telemanagement participants' compliance rate averages 89.5%. CHF hospitalization rates are 0.6/patient/year compared with the national benchmark of 1.7/patient/year. A disease management program consists of inpatient consultation, education, outpatient CHF clinic, cardiac home care, and compliance monitoring. Throughout this continuum, education must be communicated consistently by all team members. A CHF Assessment Guide assists the multidisciplinary team to thoroughly complete all education and address unique solutions to patients' needs.

214.    Iacono, L. A. (1999). Naloxone infusion and drainage of cerebrospinal fluid as adjuncts to postoperative care after repair of thoracoabdominal aneurysms [published erratum appears in Crit Care Nurse 1999 Dec;19(6):85]. Crit Care Nurse, 19(5), 37-47.
Abstract: The mechanisms that produce paraplegia in patients after TAA repair are complex and involve alterations in regional blood flow to the spinal cord, CSF dynamics, and reperfusion. Although neither the minimal level of blood flow nor the maximal spinal cord pressure that can be tolerated by the spinal cord is known, adjuncts such as CSF drainage and naloxone infusions may allow longer durations of aortic cross-clamping before irreversible ischemia occurs. Because paraplegia is multifactorial and none of the recommended adjuncts alone provides complete protection of the spinal cord, a combination of treatments may be necessary to reduce the prevalence of neurological complications after thoracoabdominal aortic reconstruction. Critical care nurses thus must be acquainted with the advanced monitoring techniques and the pathophysiology behind these new treatment modalities. Advanced assessment skills are also essential to recognize the potential neurological complications that may occur in these patients. Care of patients with TAA is a challenge. Critical care nurses must use multidimensional skills in the areas of hemodynamic monitoring, physical assessment, and psychological counseling to effectively manage postoperative care of these patients.

215.    Iacono, L. A. (1999). Naloxone infusion and drainage of cerebrospinal fluid as adjuncts to postoperative care after repair of thoracoabdominal aneurysms [corrected] [published erratum appears in CRIT CARE NURSE 1999 Dec; 19(6): 85]. Critical Care Nurse, 19(5), 37-47.
Abstract: Managing patients' postoperative care follwing surgery to repair descending thoracoabdominal aneurysms is a challenge to nurses. A care map and clinical case illustrate advanced monitoring techniques and new treatment modalities that can reduce neurological complications in these patients.   (25 ref)

216.    Holmboe, E. S., Meehan, T. P., Radford, M. J., Wang, Y., Marciniak, T. A., & Krumholz, H. M. (1999). Use of critical pathways to improve the care of patients with acute myocardial infarction [see comments]. American Journal of Medicine, 107(4), 324-31.
Notes: Comments: Comment in: Am J Med 1999 Oct;107(4):397-8
Abstract: PURPOSE: While critical pathways have become a popular strategy to improve the quality of care, their effectiveness is not well defined. The objective of this study was to investigate the effect of a critical pathway on processes of care and outcomes for Medicare patients admitted with acute myocardial infarction. SUBJECTS AND METHODS: A retrospective cross-sectional and longitudinal cohort study was made of Medicare patients aged 65 years and older hospitalized at 32 nonfederal Connecticut hospitals with a principal diagnosis of myocardial infarction during two periods: June 1, 1992, to February 28, 1993, and August 1, 1995, to November 30, 1995. The main endpoints of the cross-sectional analyses for the 1995 cohort were the proportion of patients without contraindications who received evidence-based medical therapies, length of stay, and 30-day mortality. Hospitals with specific critical pathways for patients with myocardial infarction were compared with hospitals without critical pathways. The main endpoints of the longitudinal analyses were change between 1992-93 and 1995 in the proportion of patients receiving evidence-based medical therapies, length of stay, and 30-day mortality. RESULTS: Ten hospitals developed critical pathways between 1992-93 and 1995. Eighteen of 22 nonpathway hospitals employed some combination of standard orders, multidisciplinary teams, or physician champions. Patients admitted to hospitals with critical pathways did not have greater use of aspirin within the first day, during hospitalization, or at discharge; beta-blockers within the first day or at discharge; reperfusion therapy; or use of angiotensin-converting enzyme inhibitors at discharge in 1995. The mean (+/- SD) length of stay in 1995 was not significantly different between pathway (7.8 +/- 4.6 days) versus nonpathway hospitals (8.0 +/- 4.2 days), and the change in length of stay between 1992-93 and 1995 was 2.2 days for pathway hospitals and 2.3 days for nonpathway hospitals. Patients admitted to critical pathway hospitals had lower 30-day mortality in 1995 (8.6% versus 11.6% for nonpathway hospitals, P = 0.10) and in 1992-93 (12.6% versus 13.8%, P = 0.39), but the differences were not statistically significant. CONCLUSIONS: Hospitals that instituted critical pathways did not have increased use of proven medical therapies, shorter lengths of stay, or reductions in mortality compared with other hospitals that commonly used alternative approaches to quality improvement among Medicare patients with myocardial infarction.

217.    Halliwell, D. (1999). A clinical pathway reduced length of stay, time to ambulation, and complications after hip and knee arthroplasty [commentary on Dowsey MM, Kilgour ML, Santamaria NM, et al. Clinical pathways in hip and knee arthroplasty: a prospective randomised controlled study. MED J AUST 1999 Jan 18;170:59-62]. Evidence-Based Nursing, 2(4), 123.
Abstract: Question: Does the use of a clinical pathway improve patient outcomes after hip or knee arthroplasty? Design: Randomised, unblinded, controlled trial with >/- 3 months followup. Setting: A tertiary referral hospital in Melbourne, Victoria, Australia. Patients: 175 patients who had hip or knee arthroplasty between January 1996 and December 1997. 12 patients (6.9%) were excluded after randomisation because they were having revision arthroplasty, simultaneous bilateral joint arthroplasty, arthroplasty for acute trauma, or complex tumour surgery. The remaining 163 patients (mean age 66 y, 66% women) completed >/= 3 months of follow up. Intervention 92 patients were allocated to the clinical pathway group and 71 were allocated to the control group. Patients in the clinical pathway group received "proactive" treatment whereby specific daily goals were set for the patient and the healthcare team. A written protocol identified milestones to be achieved, tests to be ordered, and daily tasks for patients and the healthcare team. Patients in the control group received "reactive" treatment, whereby the healthcare team provided care in response to the patient's condition and wants. Main outcome measures: Length of hospital stay, time to sitting out of bed, time to ambulation, complications (wound infections, chest infections, deep venous thrombosis, joint dislocation, decubitus pressure areas, failure to cope at home, and decreased range of motion after discharge), readmission for complications, and discharge snatching (between discharge destination as planned at pre-admission and actual destination after discharge). Main results: Patients in the clinical pathway group had a shorter mean length of star (7.1 v 8.6 d, p=0.01), sat out of bed earlier (1.9 v 3.4 d, p=0.001), and walked earlier (2.2 v 3.6 d, p=0.02) than patients in the control group. Fewer patients in the clinical pathway group had complications (table). The groups did not differ for number of patients who were readmitted (4.3% v 13% p = 0.06) or number of patients matched to their planned discharge destination (70% v 61%, p=0.3). Conclusion: Among patients who had hip or knee arthroplasty, proactive post-operative care guided by a clinical pathway reduced length of hospital stay, time to sitting out of bed and ambulation, and complications compared with patients who received standard reactive care.   (2 ref)

218.   Grant, E. N., Li, T., Lyttle, C. S., & Weiss, K. B. (1999). Characteristics of asthma care provided by hospitals in a large metropolitan area: results from the Chicago Asthma Surveillance Initiative. Chest, 116(4 Suppl 1), 162S-167S.
Abstract: INTRODUCTION: Little is known of the approaches of United States hospitals to the management of persons with asthma. The purpose of this study is to characterize the extent to which hospitals within a large community have implemented various types of asthma-specific health-care delivery processes. METHODS: A cross-sectional, self-administered survey was mailed to a "key informant" in asthma care at each of the hospitals in the Chicago area. The survey instrument covered the following content areas: asthma-related inpatient services, asthma-related outpatient services, selected asthma-related quality improvement activities, and asthma-related community outreach. The survey was administered between August 1996 and January 1997. RESULTS: Data were collected from respondents at 59 of the 89 eligible hospitals, yielding a response rate of 66.3%. Of the responding hospitals, 42.4% indicated they had clinical practice guidelines for inpatient asthma management, and 37.3% reported using critical pathways. Four selected aspects of bedside care were also explored. All of the responding hospitals reported routine provision of nebulization therapy at the bedside, and nearly all routinely obtained peak flow measurements (96.6%). In the area of patient instruction, 93.2% provided bedside evaluation of proper inhaler technique, and 86.4% routinely provided instruction on the use of peak flowmeters. Only 54.0% of the hospitals reported routinely administering some type of asthma education program prior to discharge. The hospitals with clinical practice guidelines in place were also more likely to have critical pathways (p < 0.01); to have asthma-specific ICU policies/guidelines/critical pathways (p < 0.01); to provide bedside instruction on the use of peak flowmeters (p < 0.01); to provide an asthma education (p < 0.01) prior to discharge; and to conduct utilization review. Very few hospitals indicated that they had community outreach programs for asthma care. CONCLUSION: The results of this survey suggest that among Chicago-area hospitals appropriate bedside care for persons with asthma is provided, but there are large variations in other types of asthma services and programs. The hospitals that have adopted asthma clinical practice guidelines are more likely to have other asthma-specific quality improvement activities than hospitals without guidelines. This relationship between use of guidelines and quality of services needs further exploration, as it may prove to be an important marker for hospitals with staff that are interested in improving asthma care.

219.    Grady, K. L., Jalowiec, A., & White-Williams, C. (1999). Preoperative psychosocial predictors of hospital length of stay after heart transplantation [see comments]. Journal of Cardiovascular Nursing, 14(1), 12-26.
Notes: Comments: Comment in: J Cardiovasc Nurs 1999 Oct;14(1):v-vii
Abstract: The effect of psychosocial factors on hospital length of stay (LOS) after heart transplantation has not been reported. This study examines relationships between preoperative psychosocial variables and LOS and identifies preoperative psychosocial predictors of LOS after transplant. A nonrandom sample of 307 patients at two medical centers completed a self-administered booklet of psychosocial measures. A chart review was also conducted. Psychosocial problems included anxiety, stress, and inadequate coping; questionable understanding of heart failure and treatment; substance abuse; and noncompliance. Self-care disability, a history of noncompliance, and more emotional disability predicted 8% of LOS. This supports the inclusion of psychosocial issues and functional disability in post-heart transplant clinical pathways.

220.    Goodwin, M. J., Bissett, L., Mason, P., Kates, R., & Weber, J. (1999). Early extubation and early activity after open heart surgery. Critical Care Nurse, 19(5), 18-22, 24-26.
Abstract: An interdisciplinary approach to developing new protocols results in improved quality of care, reduced operational costs, and faster weaning from ventilatory support. Shortened intubation times and an aggressive activity program provide improved outcomes for open heart surgery patients.   (4 ref)

221.    Fox, I., & Brown, T. (1999). Affecting patient care with perioperative clinical pathways. Surgical Services Management, 5(10), 41-2, 44-47.

222.    Chang, P. L., Wang, T. M., Huang, S. T., Hsieh, M. L., Tsui, K. H., & Lai, R. H. (1999). The implementation of clinical paths for six common urological procedures, and an analysis of variances. Bju International, 84(6), 604-9.
Abstract: OBJECTIVE: To evaluate the outcomes of treatment after implementing clinical paths for six common urological procedures, and analyse the variances from these paths. PATIENTS AND METHODS: The study comprised 1006 consecutive patients treated according to the recommendations of the clinical path for six common urological procedures; the results of treatment were compared with those from 1006 patients treated by the same physicians before implementing the clinical paths. Total admission charges were divided into five categories, i.e. operation and anaesthesia, laboratory, radiology, pharmacy and other. The differences in these five categories before and after implementation were determined; the variance data were also tracked and analysed. Five quality indicators were monitored during implementation and compared with the data before implementation. RESULTS: The mean length of hospital stay (LOS) and admission charges were significantly lower (P=0.03 and P<0.01) after implementation. The charges for laboratory, radiology, pharmacy and other were significantly decreased after the use of clinical paths. The common variations from the clinical paths were patient-related variance (33%) and discharge variance (26%). Variances affecting the LOS only or the admission charge only were more common than those affecting neither the LOS nor admission charges (both P<0.01), or both (both P<0.01). After implementation, the results of the five quality indicators were significantly improved and the number of patients with surgical complications was significantly reduced (P<0. 01), but the mortality and readmission rate did not increase. CONCLUSIONS: The implementation of clinical paths for six common urological procedures decreased the LOS, admission charges and surgical complications, and improved the quality of care. During implementation, variances can affect the LOS and/or admission charges.

223.    Berger, D. (1999). Order from chaos. Mlo: Medical Laboratory Observer, 31(10), 8.

224.    Barr, J. E. (1999). Wound care 1999. Integrating disease management and wound care critical pathways in home care. Home Healthcare Nurse, 17(10), 651-63.
Abstract: This article discusses the need for an integration of the concepts of disease management and critical pathways as a foundation of a healthcare delivery system. The steps in the process for development, implementation, and evaluation of a wound care critical pathway are reviewed and variance classifications are defined. Copathways and algorithms are presented as methodologies for dealing with variances. A template of a wound care critical pathway that has been developed for use in the home care setting is included.   (6 ref)

225.    Barr, J. E. (1999). Integrating disease management and wound care critical pathways in home care. Home Healthc Nurse, 17(10), 651-63.
Abstract: This article discusses the need for an integration of the concepts of disease management and critical pathways as a foundation of a healthcare delivery system. The steps in the process for development, implementation, and evaluation of a wound care critical pathway are reviewed and variance classifications are defined. Co-pathways and algorithms are presented as methodologies for dealing with variances. A template of a wound care critical pathway that has been developed for use in the home care setting is included.

226.    Anonymous. (1999). Ischemic stroke pathway relies on ED order sheets. RN, 62(10), 24ac7-8.

227.    Anonymous. (1999). CRITICAL PATH NETWORK. Total hip replacement pathway aims at four-day LOS. Hospital Case Management, 7(10), 175-178.

228.    Anonymous. (1999). Clinical pathways for general surgeons: abdominal revascularization. American Surgeon, 65(10), 999-1002.

229.    Anonymous. (1999). Acute care decisions. Ischemic stroke pathway relies on ED order sheets... this article was adapted from one that appeared in sister company American Health Consultants' newsletter, "Hospital Case Management". RN, 62(10), 24ac7-8.