Caremaps, Critical Paths, etc.  September 1999-Present, Part 2

     1.    Mitchell, P. (1999). How to build a record collection. Health Service Journal, 109(5674 Spec Rep), 12-13.

     2.    Hill, M. (1999). Outcomes measurement requires nursing to shift to outcome-based practice. Nursing Administration Quarterly, 24(1), 1-16.
Abstract: The measurement of outcomes to demonstrate the effectiveness of nursing care delivered is essential. This article will outline the history of outcomes measurement in nursing, the definition and levels of outcomes, the differentiation between process interventions and outcome statements, and the monitoring of outcomes at the staff nurse and case manager levels. Care management methodologies to assist in outcome management will be discussed. In the end, the development of nursing knowledge and innovation in care strategies and advanced clinical decision making is dependent on the measurement of intermediate and end result outcomes. [References: 13]

     3.    Carnett, W. G. (1999). Clinical practice guidelines: a tool to improve care. Quality Management in Health Care, 8(1), 13-21.

     4.    Wilmore, D. W. (1999). Growth factors and nutrients in the short bowel syndrome. Jpen: Journal of Parenteral & Enteral Nutrition, 23(5 Suppl), S117-20.
Abstract: Massive intestinal resection often results in long-term dependence on parenteral nutrition (TPN). In an effort to enhance bowel rehabilitation, the amino acid glutamine, growth hormone and a diet optimized to enhance absorption have been administered to >300 patients with the short bowel syndrome. Initially about 60% of the patients were weaned from TPN and an additional 30% had reduced TPN requirements. At long-term follow up (2 years) 40% of the group remained off TPN, 40% had reduced TPN requirements, and 20% had the same requirements. This report addresses issues such as the optimization of diet and provides a care map which should enhance the rehabilitation of patients with the short bowel syndrome. [References: 29]

     5.    Ironside, P. M. (1999). Thinking in nursing education. Part II. A teacher's experience. Nurs Health Care Perspect, 20(5), 243-7.
Abstract: Across academia, educators are investigating teaching strategies that facilitate students' abilities to think critically. Because may these strategies require low teacher-student ratios or sustained involvement over time, efforts to implement them are often constrained by diminishing resources for education, faculty reductions, and increasing number of part-time teachers and students. In nursing, the challenges of teaching and learning critical thinking are compounded by the demands of providing care to patients with increasingly acute and complex problems in a wide variety of settings. To meet these challenges, nurse teachers have commonly used a variety of strategies to teach critical thinking (1). For instance, they often provide students with case studies or simulated clinical situations in classroom and laboratory settings (2). At other times, students are taught a process of critical thinking and given structured clinical assignments, such as care plans or care maps, where they apply this process in anticipating the care a particular patient will require. Accompanying students onto clinical units, teachers typically evaluate critical thinking ability by reviewing a student's preparation prior to the experience and discussing it with the student during the course of the experience. The rationales students provide for particular nursing interventions are taken as evidence of their critical thinking ability. While this approach is commonly thought to be effective, the evolving health care system has placed increased emphasis on community nursing (3,4), where it is often difficult to prespecify learning experiences or to anticipate patient care needs. In addition, teachers are often not able to accompany each student to the clinical site. Thus, the traditional strategies for teaching and learning critical thinking common to hospital-based clinical courses are being challenged, transformed, and extended (5). Part II of this article describes findings that suggest how many teachers and students are challenging the conventional approaches to schooling and creating pedagogies that are more responsive to the contemporary context of health care.

     6.    Dickerson, S. S., Peters, D., Walkowiak, J. A., & Brewer, C. (1999). Active learning strategies to teach case management. Nurse Educ, 24 (5), 52-7.
Abstract: Changes in healthcare delivery require a new understanding of the concepts of case management in managed care. The authors describe the construction and evaluation of a learning module that encourages active engagement and skill development. Students develop an understanding of how to plan for care of populations in an effort to meet managed care demands. This approach to teaching case management can be effective in an educational setting and possibly in clinical settings as well.

     7.    Zusman, R. M., Chesebro, J. H., Comerota, A., Hartmann, J. R., Massin, E. K., Raps, E., & Wolf, P. A. (1999). Antiplatelet therapy in the prevention of ischemic vascular events: literature review and evidence-based guidelines for drug selection. Clinical Cardiology, 22(9), 559-73.
Abstract: BACKGROUND: New antiplatelet drugs are being developed and many clinical trials evaluating the benefits of antiplatelet drugs for the secondary prevention of ischemic events in patients with atherosclerotic vascular disease have been performed. HYPOTHESIS: An updated systematic review and evidence-based guidelines for the appropriate selection of antiplatelet drugs may be beneficial to physicians and healthcare organizations attempting to create or update current clinical practice guidelines or clinical pathways aimed at caring for these patients. METHODS: (1) A systematic review of the recent literature on the relative efficacy and safety of aspirin, ticlopidine, and clopidogrel was undertaken; (2) an evidence-based, expert panel approach using a modified Delphi technique to create explicit guidelines for prescribing antiplatelet therapy was instituted; and (3) the recommendations of an expert panel were summarized. RESULTS: Consensus guidelines were developed for the utilization of aspirin, ticlopidine, or clopidogrel for the prevention of ischemic events in patients with manifestations of atherosclerotic vascular disease (prior myocardial infarction, prior ischemic stroke, or established peripheral arterial disease) who are at increased risk for recurrent ischemic events. Based on efficacy and safety, clopidogrel was recommended as the drug of choice for patients with established peripheral arterial disease; aspirin or clopidogrel should be considered in patients with prior myocardial infarction (with clopidogrel favored for patients who have had a recurrent event while on aspirin or in whom aspirin is contraindicated); aspirin or clopidogrel should be considered as first-line treatment in patients with prior ischemic (nonhemorrhagic) stroke--however, clopidogrel is the favored drug in patients in whom other antiplatelet drugs are either contraindicated or who have had recurrent events while on therapy. CONCLUSIONS: Myocardial infarction, ischemic stroke, and peripheral arterial disease are all clinical manifestations of the same underlying disease process (atherosclerosis), with thrombus formation on the disrupted atherosclerotic plaque (atherothrombosis) being a common precipitating factor of ischemic events in patients suffering from these disorders. An evidence-based approach was used to develop a practice guideline, based on available published evidence, for the appropriate utilization of antiplatelet agents (aspirin, ticlopidine, or clopidogrel). These guidelines may be of use to multidisciplinary teams wishing to create or update clinical guidelines or clinical pathways which address the care of patients with atherosclerotic vascular disease. New antiplatelet agents such as clopidogrel may be more effective and associated with lower risk of selected adverse effects (such as gastrointestinal distress, gastrointestinal hemorrhage, and neutropenia) than those previously used to prevent thrombus formation in the setting of atherosclerotic arterial disease. Combination antiplatelet therapy is being evaluated as an option for those patients who experience recurrent events on a single antiplatelet agent. [References: 86]

     8.    Wroblewski, M., Werrbach, K., & Gattuso, M. C. (1999). Nurses gain more time with patients. Nursing Management (Chicago), 30(9), 35-6.
Abstract: Clinical pathways that incorporate charting by exception eliminate repetitive documentation and give nurses more time to educate and care for patients. In this case, nurses report a gain of 15 minutes per patient each day.

     9.    Siegel, R. E. (1999). Strategies for early discharge of the hospitalized patient with community-acquired pneumonia. Clinics in Chest Medicine, 20(3), 599-605.
Abstract: The treatment of the hospitalized patient with uncomplicated CAP is changing, to include a brief period of intravenous antibiotics followed by oral therapy. The Classification of Community-Acquired Pneumonia or CoCAP is a stratification tool that categorizes patients as low-risk pneumonia, unstable pneumonia, or complicated pneumonia. Use of validated hospital admission criteria, combined with the CoCAP algorithm and evolving criteria for switching patients from intravenous to oral therapy provides a structure for organizing treatment of patients with CAP for caregivers. Patients who can be discharged early are those from the unstable pneumonia group, which includes patients who have had reversal of their metabolic problems and stabilization of comorbid conditions, and who have not developed any serious pneumonia-related complications. Prolonged courses of intravenous antibiotic therapy are being replaced with 2 to 3 day courses of intravenous hydration and antibiotics; a switch to oral therapy and hospital discharge can be achieved after the patient tolerates one dose of oral therapy. Parameters to watch include vital signs and white blood cell count. Provided these parameters are improving, although they may not have returned to normal, the patient can be switched to oral therapy. Although patient treatment guidelines and critical pathways are becoming widespread in disease management, CAP is one disease in which prospective studies have demonstrated that a reduction in hospital stay is safe. Patients, caregivers, and administrators are happy with the reduction in hospital LOS. Other treatment protocols are being explored, including a single dose of intravenous antibiotic prior to oral switch and all-oral regimens employing the newer fluoroquinolones. [References: 29]

   10.    Orsted, H., & Attrell, E. (1999). Making clinical practice guidelines work: the experience of one home healthcare agency. Ostomy Wound Management, 45(9), 48-54, 56; quiz 58-59.
Abstract: Almost 20 years have passed since clinical practice guidelines were introduced into the healthcare system and they have permeated into every area of clinical practice. Originally clinical practice guidelines were regarded, by healthcare chief executive officers, as "the answer" to the need to reduce inappropriate or unnecessary variation in clinical practice. Between 1990 and 1996, the U.S. Agency for Health Care Policy and Research introduced 19 practice guidelines in an effort to support evidence-based methods to assess medical treatments and to set high standards for the development of guidelines. This article will explore the development and/or adoption and clinical application of guidelines into practice. [References: 20]

   11.    Linko, J. L. (1999). Too little, too late?... AMR, Kaiser sign agreement, vital signs, June 1999. Emergency Medical Services, 28(9), 12.

   12.    Gow, J. (1999). Costs of screening for colorectal cancer: an Australian programme. Health Economics, 8(6), 531-40.
Abstract: The total costs (direct and indirect) associated with the operation of an Australian community based screening programme for colorectal cancer (CRC) were estimated. One-year costs of the programme were estimated to be AUS$1 347 948 to screen 24 000 participants. This corresponded to AUS$8868 per polyp and AUS$28 679 per cancer detected. The results presented here are quite favourable compared with the only other Australian screening programme that has reported costs. That programme estimated a cost per cancer detected of AUS$24 233 (adjusted). The recent Australian public health literature has been almost unanimously against recommending the operation of population based CRC screening programmes. More recently, overseas randomized control trials have reported reduced mortality (15 to 33%) as a result of these programmes. Cost data, as presented here combined with the epidemiological evidence, indicate the challenge the Federal Government is now confronted with in formulating policy to control the increasing number of deaths from the disease. Copyright 1999 John Wiley & Sons, Ltd.

   13.    Gonzalez, E. R. (1999). Low-molecular-weight heparins for acute coronary syndromes: an emergency medicine perspective. Pharmacotherapy, 19(9 Pt 2), 155S-160S.
Abstract: Patients with chest pain represent one of the largest and most challenging populations for emergency departments to treat. Diagnostic and treatment modalities implemented in the emergency department are associated with significant clinical outcomes and financial implications. Critical pathways are being developed to increase the speed and efficiency with which these patients are managed. Of particular importance is the evolving role of low-molecular-weight heparins, which have both clinical and economic advantages over unfractionated heparins in treating unstable angina and non-Q wave myocardial infarction. [References: 32]

   14.    Dykes, P. C., & Wheeler, K. (1999). Evidence-based practice for nurse practitioners with clinical pathways. Clinical Excellence for Nurse Practitioners, 3(5), 291-7.
Abstract: Evidence-based practice is essential for clinical excellence for nurse practitioners (NPs). Client outcomes must be measured and clearly linked to measurable nursing interventions. To ensure evidence-based practice, clinical pathways can be used as a vehicle to implement care. Clinical pathways track outcomes and interventions, and provide a means for accurate documentation. This article discusses evidence-based practice and the use of clinical pathways by psychiatric NPs in two settings: home care and an outpatient psychiatric clinic.   (24 ref)

   15.    Chang, P. L., Huang, S. T., Hsieh, M. L., Wang, T. M., Tsui, K. H., & Lai, R. H. (1999). Does the use of clinical paths improve the efficiency and quality of care under the case payment system for inguinal herniorrhaphy or transurethral prostatectomy?. Chang-Keng i Hsueh Tsa Chih, 22(3), 400-8.
Abstract: BACKGROUND: We evaluated the effects of implementing clinical paths for both inguinal herniorrhaphy (IH) and transurethral prostatectomy (TURP) on the efficiency and quality of medical care under the case payment system. METHODS: Patients undergoing IH or TURP were treated using the guidelines for clinical paths under the case payment system (CPUCP). The results of treatment after implementation of CPUCP were compared with results for patients treated before implementation of CPUCP. We also compared results using eight quality indicators both before and after implementation of CPUCP. RESULTS: The post-CPUCP length of hospital stay decreased significantly in patients who underwent either IH (p < 0.001) or TURP (p = 0.008). The post-CPUCP total admission charges decreased (p = 0.001) by 7.5% in the IH group alone. Two quality indicators in the IH group and three quality indicators in the TURP group were significantly improved after implementation of CPUCP. The percentage of patients who completed treatment without deviation as recommended by the guidelines for CPUCP was about 60% in the IH group and about 70% in the TURP group. CONCLUSION: The results of this study indicate that the implementation of clinical paths under the case payment system for patients undergoing inguinal herniorrhaphy or transurethral prostatectomy can improve the efficiency and quality of medical care.

   16.    Calver, P., Rider, M., Hetrick, D., & McGraw, J. (1999). CRITICAL PATH NETWORK. Developing an acute cardiac evaluation unit for MI patients. Hospital Case Management, 7(9), 157-160.

   17.    Bennett, J. (1999). Integrated care pathways -- should they be paperless? Itin, 11(3), 3-5.

   18.    Barker, S. G., Sachs, R., Louden, C., Linnard, D., Abu-Own, A., Buckland, J., & Murphy, S. (1999). Integrated care pathways for vascular surgery. European Journal of Vascular & Endovascular Surgery, 18(3), 207-15.
Abstract: OBJECTIVES: a trial of the use of integrated care pathways (ICPs) for elective vascular surgical procedures. DESIGN: a 12-month prospective study, following a multi-disciplinary group construction of current "best practice" ICPs, with changes in practice only occurring following careful audit of results. MATERIALS: patients admitted to a single vascular unit for "open" repair of abdominal aortic aneurysm, carotid endarterectomy or femoropopliteal bypass grafting. METHODS: patients followed ICPs on a daily basis with signatures required to confirm that action had been taken and careful recording of variances from the ICPs. Audit of variance data allowed changes in the ICPs and, hence, provision of the best possible nursing and clinical practice. RESULTS: ICPs were well received by patients and staff. They improved communication, promoted an appreciation of each health group's role in patient care, increased nursing autonomy, reduced calls to junior medical staff, improved patient education and confidence and caused a marked reduction in hospital "length of stay". CONCLUSIONS: ICPs have clear benefits. This study realises that benefits might be maximal for high throughput, high-cost procedures. Successful use of ICPs depends upon "clinical champions" and effective project management. Sufficient resource and training are essential. Copyright 1999 Harcourt Publishers Ltd.

   19.    Herring, L. (1999). Critical pathways: an efficient way to manage care. Nursing Standard, 13(47), 36-7.
Abstract: Liz Herring argues that care pathways provide a change in the traditional approach to planning and documenting care. She suggests that they provide opportunities for the more efficient use of nursing time and resources.

   20.    Waggoner, M. G. (1999). Clinical pathways: from the hospital to the home. MEDSURG Nursing, 8(4), 265-6.

   21.    Veltman, R., & Loppnow, N. (1999). Improving care for patients having abdominal hysterectomy. Hospital Case Management, 7(8), 139-42.

   22.    Tolson, D. (1999). Practice innovation: a methodological maze. Journal of Advanced Nursing, 30(2), 381-90.
Abstract: Practice innovation is an inevitable feature of a health culture preoccupied with evidence-based practice. The cyclical process of defining best practice, implementing and evaluating change represents an unparalleled opportunity for nurse researchers to engage in, and develop, practice through 'realistic evaluation'. However, the methodological dilemmas and challenges inherent in evaluation research which informs policy should not be under-estimated. This paper seeks to introduce and wrestle with some of the political tensions and methodological issues surrounding practice innovation when it is undertaken within an evaluative research framework. A critical pathway is presented to stimulate discussion and guide novice evaluators through this often perplexing methodological maze. A case study in audiological rehabilitation in elder care is used to illustrate the issues raised.   (38 ref)

   23.    Shima, K., Zhu, M., & Mizuno, A. (1999). Pathoetiology and prevention of NIDDM lessons from the OLETF rat. Journal of Medical Investigation, 46(3-4), 121-9.
Abstract: The OLETF rat, a genetic model of spontaneous development of NIDDM, exhibits hyperglycemic obesity with hyperinsulinemia and insulin resistance similar to that in humans. It is still unclear whether a defect in the beta-cell proliferation per se is the primary pathogenetic event in this model rat. To clarify this matter, we used partially pancreatectomized rats as a model. Male rats of 6 weeks of age were allocated at random to two groups: 70% pancreatectomy (Px) and sham-pancreatectomy (sham). Each group was divided into 4 subgroups by the date of sacrifice after surgery. Sustained hyperglycemia was evident in the Px OLETF rats after surgery. This was associated with insufficient proliferation of beta-cells, characterized by a decrease in beta-cell labeling with 5-bromo-2' deoxyuridine in proportion to a decrease in beta-cell mass and reduction in insulin content in the remnant pancreas. Administration of nicotinamide, however, ameliorated the sustained hyperglycemia by increasing beta-cell proliferation. These findings suggest that OLETF rats have a poor capacity for proliferation of pancreatic beta-cells, and that this change may be the critical pathogenetic event prior to the onset of overt diabetes. OLETF rats following long-term caloric restriction and spontaneous exercise training show normal glucose tolerance accompanied by an increase in GIR as shown by a euglycemic clamp. Both exercise training and caloric restriction normalize the abnormalities in the pancreas such as marked hypertrophy of islets and hyperplasia of connective tissues in islets. It is particularly noteworthy that exercise training significantly elevated the beta-cell mass/body weight ratio. This evidence obtained from OLETF rats may be of value when the mechanism of diet and exercise effects on diabetic patients are considered. [References: 31]

   24.    Ornato, J. P. (1999). Chest pain emergency centers: improving acute myocardial infarction care. Clinical Cardiology, 22(8 Suppl), IV3-9.
Abstract: Uncertainty and delay are common in the diagnosis of acute coronary syndromes (ACS). In the last 20 years, the need for faster, more accurate, and more cost-effective diagnosis gave rise to the concept of specialized treatment of patients with chest pain in emergency departments (EDs). The original strategy dedicated a separate section of the ED and a nursing staff to the task of rapid intervention in patients with acute myocardial infarction (MI) and triage of low-risk patients. Chest pain centers grew quickly in popularity but evolved with a variety of goals, staffing plans, diagnostic resources, and levels of commitment. There existing centers--the University of Cincinnati Heart ER, Brigham and Women's Hospital, and the Medical College of Virginia--have implemented chest pain strategies with the common aims of (1) screening for the entire spectrum of coronary artery disease, (2) avoiding unnecessary admissions, and (3) using multiple diagnostic modalities. Yet, they differ in the specifics of their approaches and diagnostic methods (e.g., echocardiography vs. treadmill vs. myocardial perfusion imaging). The safety and cost effectiveness of these centers are discussed. [References: 25]

   25.    Marrie, T. J. (1999). Clinical strategies for managing pneumonia in the elderly. Clinical Geriatrics, (Suppl), 6-10.

   26.    Kayser, K., & Kayser, G. (1999). Basic aspects of and recent developments in telepathology in Europe, with specific emphasis on quality assurance. Analytical & Quantitative Cytology & Histology, 21(4), 319-28.
Abstract: Telepathology is the diagnostic work of a pathologist from a distance and includes all specific fields of diagnostic pathology, such as frozen section services, expert consultation, cytometric and histometric measurement, and continuous education. For about 15 years experience has been collected at several universities in the United States and Europe based upon analog telephone lines (9.2 kbaud), digitized lines (ISDN, 64 kbaud), broad band connections (1.5 Mbaud) and the World Wide Web (28 kbaud). Potential use can be expected in the application of telepresentation, remote slide preparation, remote central diagnostics and telediscussion. The transfer of still images is well developed; that of live images is used in only a few institutions for frozen section services. The image quality and spatial resolution as well as the transfer speed are sufficient for expert consultations, morphometric measurements, quality assurance and education. All applications focus on discontinuous work flow. Although the European Community focuses on user needs and standardization aspects of telepathology by sponsoring a widespread telepathology project (Europath), implementation of telepathology into routine application in the continuous work flow has still to be developed. The technical equipment has still to be adjusted to the labor flow charts in routine pathologic diagnostic procedures. Telepathology seems to be the appropriate technique to offer both improvement in diagnostic quality and inclusion of the "control institution" into diagnostic responsibility. [References: 29]

   27.    Fisch, L., & Schenk, L. A. C. (1999). Managers forum. Care plans/care tracks. How are other departments developing a plan of care for the ED patients they see frequently? Journal of Emergency Nursing, 25(4), 313-314.

   28.    Colaneri, J. (1999). A balanced scorecard approach to quality improvement in a renal transplant program. Nephrol News Issues, 13(8), 19, 23-6.

   29.    Cannon, C. P. (1999). Incorporating platelet glycoprotein IIb/IIIa inhibition in critical pathways: unstable angina/non-ST-segment elevation myocardial infarction. Clinical Cardiology, 22(8 Suppl), IV30-6.
Abstract: Platelet glycoprotein (GP) IIb/IIIa inhibitors have been shown to be effective in reducing thrombotic events in patients with acute coronary syndromes undergoing percutaneous coronary intervention (PCI) and when used as medical therapy in patients with unstable angina/non-ST-segment elevation myocardial infarction (MI). Recent findings include dramatic preventive benefits in the setting of coronary stent deployment and a significant long-term preventive effect on mortality. The benefits of GP IIb/IIIa receptor inhibition suggest the utility of adopting routine use of these agents in critical pathways of unstable angina/non-ST-segment elevation MI and PCI. Because cost constraints may limit use of these agents, however, targeting treatment based on patient risk assessment may be warranted. [References: 31]

   30.    Anonymous. (1999). Standardizing ventilator, protocols can save millions in ICU. Quality Letter for Healthcare Leaders, 11(8), 14-9.

   31.    Anonymous. (1999). GynCare: how one IPA got better clinical outcomes and a closer culture. Medical Network Strategy Report, 8(8), 1-7.
Abstract: When is a medical management opportunity a corporate culture opportunity? The folks at Hill Physicians Group in the San Francisco Bay Area found out when they launched a pilot program to try to improve the management of gynecological surgeries. In an example of the increasingly inter-twined challenges of medical management under managed care, physicians, clinical managers, and others at this sophisticated Northern California IPA have seen their efforts to improve the delivery of women's healthcare pay off, with shifts in surgical approaches that produced impressive results, plus unexpected benefits to the organization's physician culture. But no one's saying it was an easy process.  (Abstract by: Author)

   32.    Dandy, D. (1999). Assessment tool promotes continence after childbirth. Nursing Times, 95(28), 42-3.
Abstract: This article looks at how midwives, health visitors and continence advisers are working together in Sandwell in the West Midlands to promote women's health. By acknowledging the evidence that certain factors associated with childbirth can predispose women to incontinence, a risk-assessment tool has been developed providing a process for women to achieve continence health postnatally.

   33.    Janken, J. K., Grubbs, J. H., & Haldeman, K. (1999). Clinical column. Toward a research based critical pathway: a case study. Online Journal of Knowledge Synthesis for Nursing, (Doc N 1C), no pagination.

   34.    Ellis, B. W., & Johnson, S. (1999). The care pathway: a tool to enhance clinical governance. Clin Perform Qual Health Care, 7(3), 134-44.
Abstract: A care pathway defines in detail the individual components of treatment for a group of patients. A well-written pathway can lead to consistent care of the highest quality. There are both educational and audit advantages to the approach. The authors detail the means by which groups are selected and the care pathways written. An example of the benefits that can accrue comes from their experience at Ashford Hospital of running a pathway for patients having prostate surgery. The pathways are appreciated by patients, nurses, doctors and managers. Care is improved, costs contained and clinical governance enhanced.

   35.    Warner, P. M., & Hutchinson, C. (1999). Heart failure management. Journal of Nursing Administration, 29(7/8), 28-37.
Abstract: Patients with congestive heart failure consume a large portion of healthcare dollars. After the implementation of an outpatient inotropic infusion unit, case management, a restorative care pathway, and telemanagement at a community hospital, the number of hospital admissions, the inpatient length of stay, and overall costs decreased. At the same time, customer satisfaction and functional status increased. This article describes how the improved outcomes were accomplished.   (5 ref)

   36.    Plociak, B. J., Lato, A., & Palumbo, M. (1999). Case study: fractured ankle. Orthopaedic Nursing, 18(4), 21-26.
Abstract: To improve our practice performance for patients admitted to the emergency department with fractured ankles, our Clinical Quality Improvement Team (CQI) developed the Fractured Ankle Critical Path, for patients needing open reduction and internal fixation, but for whom surgery could or should be deferred as determined by the orthopaedic surgeon. Members of the team included an orthopaedic trauma surgeon, an emergency department physician, case managers, and representatives of the Home Care Department at Rhode Island Hospital. The critical path includes a Home Care referral procedure, an R.I. Hospital Fracture and Orthopaedic Information Sheet, and a Fractured Ankle Home Care Protocol. The goal of the Fractured Ankle Critical Path is to decrease length of stay while maintaining positive outcomes.

   37.    Pinski, S. L., & Helguera, M. E. (1999). Antiarrhythmic drug initiation in patients with atrial fibrillation. Progress in Cardiovascular Diseases, 42(1), 75-90.
Abstract: Antiarrhythmic drugs remain the mainstay of treatment of atrial fibrillation, but their potential proarrhythmic effects hamper their optimal use. Drug-induced tachyarrhythmias (ventricular tachycardia or atrial tachyarrhythmias with rapid ventricular response) are life-threatening and often cause syncope. Because these events tend to cluster shortly after drug initiation, it is common practice to routinely hospitalize patients for drug initiation under continuous electrocardiographic surveillance. The low incidence of serious proarrhythmia makes the cost-effectiveness of this practice controversial. Torsades de pointes, in particular, can be predicted by the presence of one or more of the following risk factors: female gender, structural heart disease, prolonged baseline QT interval, bradycardia, hypokalemia, previous proarrhythmic responses, and higher drug plasma levels. Proarrhythmia induced by class IC agents is seen almost exclusively in patients with structural heart disease and ventricular dysfunction. A variety of monitoring devices permit electrocardiographic monitoring of patients in the outpatient setting. Efficient clinical pathways for the safe initiation of antiarrhythmic drugs in patients with atrial fibrillation do not require universal hospital admission. In patients without structural heart disease, outpatient initiation of most antiarrhythmic drugs appears safe. In patients with significant structural heart disease, class IC drugs are contraindicated, and most other drugs should be initiated in the hospital under continuous monitoring. The incidence of severe proarrhythmia is very low when loading doses of amiodarone of 600 mg/d or less are given to outpatients with structural heart disease. [References: 135]

   38.    Budimlic, L. A. (1999). Case management in long-term care settings. Case Manager, 10(4), 81-85.

   39.    Bringewatt, R. J. (1999). Reinventing managed care for the chronically ill. Healthplan, 40(4), 67-71.

   40.    Benham, A. J. (1999). Managed care and critical pathway development: the joint replacement experience. Orthopaedic Nursing, 18(4), 71-5.
Abstract: This article examines the economic, social, ethical, and political issues affecting total joint replacement patients in a managed care environment. Using general systems theory as a framework, it examines the interrelated historical events that have shaped the development of both joint replacement procedures and managed care, and discusses the extent to which these two phenomena have been mutually influential. Specifically, the article examines the initial development, implementation, and continuing evolution of clinical pathways as an easily identified and relatively discrete manifestation of managed care for the joint replacement population. While the overall impact of managed care is beyond the scope of this presentation, it is hoped that a focus on the practical application of clinical pathways to joint replacement will allow some general principles to emerge that may be useful for both patients and practitioners operating in other aspects of the managed care environment.   (19 ref)

   41.    Anonymous. (1999). Stroke: occupational therapy considerations when predicting outcomes and designing therapy. Focus on Geriatric Care & Rehabilitation, 13(3), 1, 3-11.

   42.    Sladek, M. L., Swenson, K. K., Ritz, L. J., & Schroeder, L. M. (1999). A critical pathway for patients undergoing one-day breast cancer surgery. Clinical Journal of Oncology Nursing, 3(3), 99-106.
Abstract: As the trend of surgical procedures shifting from inpatient to outpatient settings continues, outpatient-focused standardized care processes will become more of a necessity. A multidisciplinary critical pathway (CP) for breast cancer surgery can assist care providers in meeting patients' educational and psychosocial needs. The CP document discussed in this article takes into account the expedient nature of outpatient surgery and spans the continuum of care from the surgical clinic to the postoperative homecare visit. Integrating homecare nursing improves the quality and consistency of care.

   43.    Moore, C. E., Ross, D. A., & Marentette, L. J. (1999). Critical pathways in anterior cranial base surgery. Otolaryngology & Head & Neck Surgery, 121(1), 113-8.

   44.    Moloney, R., & Maggs, C. (1999). A systematic review of the relationships between written manual nursing care planning, record keeping and patient outcomes. Journal of Advanced Nursing, 30(1), 51-7.
Abstract: A systematic review of research literature published in English between 1987 and 1997 was carried out to test the hypothesis that care planning and/or record keeping in nursing practice has no measurable effect on patient outcomes. The study was limited to research applicable to acute in-patient care and to non-information technology based recording. A search strategy was agreed with the steering group and search terms refined as the study progressed. Using the guidelines from the University of York National Health Service Centre for Reviews and Dissemination (NHS Centre for Reviews 1995), a data extraction proforma was constructed. An initial search revealed approximately 300 possible abstracts for discussion. Further analysis limited this to 43 studies, of which 30 were rejected as having too little information. Of the remaining 13 studies, none was sufficiently robust to be included in the review. The hypothesis can be neither accepted nor rejected. This has important consequences for nursing practice and management and for research. A multi-centre rigorous study is recommended.   (19 ref)

   45.    Leslie, C., Schlegel, V., & Taylor, E. L. (1999). Psychiatric hospital's discharge planning streamlined. Hospital Case Management, 7(7), 123-6.

   46.    Gooding, T. D., Newcomb, L., & Mertens, K. (1999). Patient-centered measurement at an academic medical center. Joint Commission Journal on Quality Improvement, 25(7), 343-51.
Abstract: BACKGROUND: Harborview Medical Center (Seattle, Wash) has collected patient data on operations since 1988 and has participated in the University HealthSystem Consortium's (UHC; Oak Brook, III) patient satisfaction measurement program since 1996. The patient feedback program is intended to provide data suitable for the quality improvement process and benchmark Harborview's performance against that of other academic medical centers (AMCs). USE OF PATIENT FEEDBACK AT HARBORVIEW: The Picker Institute Adult Inpatient survey's seven dimensions of care are used to disseminate the patient data and focus the action plans. The areas with the largest problem scores and the highest correlation with overall satisfaction are identified, and then specific actions are devised to address those areas. For example, patient satisfaction data collected in May 1997 led the quality council to highlight information and education as an area for improvement for both inpatients and outpatients. Patients reported that they often got answers they could not understand. Also, they did not always get enough information at discharge to feel comfortable about going home. A Discharge/Transition Center CQI (continuous quality improvement) team was charged with developing a discharge/transition process that ensures continuity of care for patients as they move throughout the system. In addition, a hospitalwide Patient and Family Information team has been working on improving information delivery by developing both patient-friendly processes and useful educational materials. FUTURE DIRECTIONS: Harborview will continue to gather feedback through not only more targeted, specific surveys but also focus groups, which have been conducted around specific issues such as diabetes care, clinical pathways, pain management, and teen health.

   47.    Goebel, R. H., & Goebel, M. R. (1999). Clinical practice guidelines for pressure ulcer prevention can prevent malpractice lawsuits in older patients. Journal of Wocn, 26(4), 175-84.
Abstract: Objective: To evaluate the impact of implementation of and compliance with practice guidelines for pressure ulcer (PU) prevention using medical malpractice litigation data. Setting and Subjects: Forty-nine plaintiffs whose respective compensations ($14,418,770 in 35 plaintiffs) or dismissals had been reported in 2 legal databases. PU verdicts and settlements for plaintiffs 60 years of age and older were evaluated using the American Geriatric Society's Clinical Practice Guidelines, "Pressure Ulcers in Adults: Prediction and Prevention." Methods: Litigation analysis was used to identify the effect, implementation of, and compliance with PU prevention practice guidelines on malpractice awards in PU lawsuits. Data were obtained using fact patterns from 2 legal databases, LEXIS and WESTLAW. Potential decreases in plaintiff awards and prevention of disability were calculated assuming that health care defendants had modified their behavior to conform to the practice guidelines. Possible increases in defendant awards were used to estimate the added risks to health care professionals of adopting these guidelines as the standard of care. Main Outcome Measures: Projected changes in verdicts, monetary awards expressed in dollars, and disability score. Results: Had health care defendants followed these guidelines, $11,389,989 might have been saved in 20 lawsuits. Violations of guidelines appeared to "cluster" together, with many plaintiffs alleging breeches of several interrelated guidelines. It appears that improving the level of care required to remedy 1 guideline variation could improve the outcomes for the entire cluster. In contrast, the use of the guidelines in court as the standard of care against defendant health care professionals might have contributed to changing only 4 of 14 defense verdicts. Conclusions: Use of clinical pathways in these settings can benefit both caregivers and patients by favorably modifying preventive practice patterns while decreasing vulnerability to litigation. Conversely, the continuing threat of fault-based litigation against substandard practitioners and facilities provides an ongoing safeguard of patient rights and reduces the risk of subsequent disability.   (47 ref)

   48.    Anonymous. (1999). Practice corner. Practice tips from the University of Alabama at Birmingham Hospital. Oncology Nursing Forum, 26(6), 975-978.

   49.    Anonymous. (1999). CABG path cuts recovery LOS to one post-op day: ventilation time is cut from 12 hours to six... coronary artery bypass graft. Hospital Case Management, 7(7), 127-131.

   50.    Spath, P. (1999). How case managers can help reduce medical errors. Hospital Case Management, 7(6), 101-3.
Abstract: Although mistakes are inevitable, even in the best-run organizations, the tools used for care coordination--such as clinical pathways, standing order sets, algorithms, and other "point of care" reminders--are among the most important weapons in the fight against medical errors in hospitals. For example, establish maximum doses for high-risk drugs, and incorporate these criteria into pathways or standing orders. Preprinted order sets and protocols allow staff to focus their attention on relevant patient care issues, rather than spending time rewriting orders and possibly introducing errors into the system. Case managers can be particularly effective in helping other caregivers catch and correct mistakes before the patient is harmed.  (Abstract by: Author)

   51.    Parson, C. (1999). Evidence-based clinical outcome management in interventional cardiology. Crit Care Nurs Clin North Am, 11(2), 143-57.
Abstract: In conclusion, through the use of pathways and case management, evidence-based clinical outcome management has occurred. The author's institution now has a process that enables it to accomplish three objectives: (1) the ability to track outcomes, (2) the ability to obtain information about opportunities for improvement and develop action plans for this, and (3) the ability to judge through continued variance analysis whether the actions taken made a difference or whether more changes are necessary. Based on this evidence, supported by the literature, the author's institution has been able to offer quality patient care at a reasonable cost.

   52.    Lavender, T., Wallymahmed, A. H., & Walkinshaw, S. A. (1999). Managing labor using partograms with different action lines: a prospective study of women's views [see comments]. Birth, 26(2), 89-96.
Notes: Comments: Comment in: Birth 1999 Jun;26(2):97-8
Abstract: BACKGROUND: The precise timing of medical intervention for women in prolonged labor is the subject of considerable debate. The partogram action line is a tool to assist practitioners in the correct diagnosis of prolonged labor. Despite its widespread use, the precise timing of the action line has not been rigorously studied, and women's views have rarely been sought. The aim of this study was to assess the effect on maternal satisfaction of managing labor using partograms with action lines drawn at 2, 3, or 4 hours to the right of the alert line. METHODS: As part of a large pilot randomized controlled trial, women's views were explored using a specifically designed questionnaire that was completed by 615 primiparas 2 days after giving birth. The quantifiable data were analyzed by comparing means using ANOVA followed by the Scheffe test. RESULTS: Women in the 2-hour arm were significantly more satisfied than those in the other two arms (p < 0.001), despite having the most obstetric intervention. CONCLUSIONS: For women in prolonged labor, obstetric intervention can be an acceptable or even favorable option. Midwives and obstetricians need to provide labor management that takes into account the preferences of the women to whom they give care.

   53.    Krenzer, M. E. (1999). Unplugging the mystery of carotid endarterectomy patient care. Crit Care Nurs Clin North Am, 11(2), 189-208.
Abstract: The first two goals of health care must always be quality care and achievement of patient outcomes. In today's health care environment, these goals are achieved with an eye on the financial picture. Cost-saving efforts by decreasing LOS, decreasing the use of ICUs, and lowering laboratory and radiologic expenses without affecting the quality of care are requirements in today's setting. The process of creating a clinical pathway for patients undergoing CEA can help to examine your care and determine evidence-based practice.

   54.    Jannik, G. T. (1999). Critical radionuclide/critical pathway analysis for the U.S. Department of Energy's Savannah River Site. Risk Analysis, 19(3), 417-26.
Abstract: Many different radionuclides have been released to the environment from the Savannah River Site (SRS) during the facility's operational history. However, as shown by this analysis, only a small number of the released radionuclides have been significant contributors to potential doses and risks to off-site people. This article documents the radiological critical contaminant/critical pathway analysis performed for SRS. If site missions and operations remain constant over the next 30 years, only tritium oxide releases are projected to exceed a maximally exposed individual (MEI) risk of 1.0E-06 for either the airborne or liquid pathways. The critical exposure pathways associated with site airborne releases are inhalation and vegetation consumption, whereas the critical exposure pathways associated with liquid releases are drinking water and fish consumption. For the SRS-specific, nontypical exposure pathways (i.e., recreational fishing and deer and hog hunting), cesium-137 is the critical radionuclide.

   55.    Jacobsen, T., & Hill, M. (1999). Achieving information systems support for clinical integration. Journal of Nursing Administration, 29(6), 31-9.

   56.    Dines, C. M. (1999). Improving renal transplant pain management. Hospital Case Management, 7(6), 105-7.

   57.    Clark, J. A., Kotyra, L. G., & Brocious, T. (1999). Rapid progression following cardiac surgery. Crit Care Nurs Clin North Am, 11(2), 159-75.
Abstract: This article examines one institution's transition into rapid progression after cardiac surgery. This includes clinical guidelines and the integral use of outcomes measures to govern care. Fast-track initiatives are examined in the scope of cost containment. A comprehensive, multidisciplinary approach is emphasized throughout.

   58.    Barber, D. B., Woodard, F. L., Rogers, S. J., & Able, A. C. (1999). The efficacy of nursing education as an intervention in the treatment of recurrent urinary tract infections in individuals with spinal cord injury. Sci Nursing, 16(2), 54-6.
Abstract: Urinary tract infection (UTI) continues to be the most frequent secondary medical complication experienced by persons with spinal cord injury (SCI). We developed a carepath designed to minimize recurrent UTIs in patients identified as at risk. Data were collected in a prospective fashion for 1,000 consecutive days at an outpatient SCI clinic. The number of UTIs decreased to below threshold in 65 percent of the patients when the nurse clinician counseled them regarding proper technique and hygiene related to clean intermittent catheterization. Of the patients who responded to this intervention, 73 percent required multiple counseling sessions. We conclude that educational intervention by a clinic nurse is a simple, cost-effective means of decreasing the risk of UTIs in individuals with SCI who are identified as at risk.

   59.    Anonymous. (1999). What you can do to optimize your hospital's reimbursement. Hospital Case Management, 7(6), 97-100.
Abstract: By paying attention to how coding is performed and documented, case managers can make significant impact on the hospital's bottom line by helping optimize reimbursement and reduce the number of claims denials. Coding is a particularly important consideration when you're examining data in terms of your case mix index. If coding data aren't accurate, then the strategies you use to improve efficiency and effectiveness might be directed inappropriately. Worse yet, if your case mix index appears to be too high, federal investigators could target your hospital for an upcoding investigation. Pay particular attention to coding issues when designing critical pathways and other performance improvement efforts. Eliminating an apparently unnecessary test may cut costs slightly, but it also may prevent your hospital from validating a high-paying diagnosis.  (Abstract by: Author)

   60.    Anonymous. (1999). Demonstrate effectiveness of your CM program. Hospital Case Management, 7(6), 100-1.
Abstract: In evaluating the performance of your case management department, go beyond broad measures such as length of stay and costs or charges per case, experts recommend. Evaluate pathways in particular in terms of other factors, such as complications, clinical outcomes, patient satisfaction, and hospital readmissions. Remember as well that your idea of a successful case management program may differ from that of a hospital administrator. So, in addition to looking at standard clinical and financial outcomes measures, it's important to consider such things as whether case management has helped the hospital increase market share or identify potential business opportunities. Managed care organizations have their own expectations as well. They tend to evaluate programs along disease-specific "product lines." If managed care case managers begin focusing more on your management of one particular disease or market, it may mean they've targeted it as an area of potential overutilization.  (Abstract by: Author)

   61.    Waters, J. B., Wolff, R. S., Blansfield, J., LaMorte, W. W., Millham, F. H., & Hirsch, E. F. (1999). Development and implementation of clinical pathways for the management of four trauma diagnoses. Journal for Healthcare Quality: Promoting Excellence in Healthcare, 21(3), 4-11, 52.

   62.    Taylor, P. (1999). Case management program for breast cancer education. Lippincott's Case Management, 4(3), 135-44.

   63.    Saddler, D. A. (1999). Education for the gastroenterology cancer patient. Gastroenterology Nursing, 22(3), 121-6.
Abstract: Education for the adult gastroenterology cancer patient requires incorporation of standards of care from both an oncology and a gastroenterology focus. In addition, standards of oncology education and role delineations for the gastroenterology/endoscopy nurse provide optimal support for the nurse-teacher working with patients with cancer of the gastrointestinal (GI) tract. The development of a teaching plan and a philosophy for teaching provide the basis for the delivery of care relative to the learning needs of this patient population. [References: 8]

   64.    Pederson, C., & Bjerke, T. (1999). Pediatric pain management: a research-based clinical pathway. Dimensions of Critical Care Nursing, 18(3), 42-51.
Abstract: Nurses want to provide pain management for pediatric patients, but different approaches lead to inconsistent pain management. This article presents a pediatric pain management clinical pathways developed as a result of research in the pediatric intensive care unit and based on pain management research. Using this pathway can help nurses deliver consistent pain management to pediatric patients.

   65.    Cervizzi, K., & Edwards, P. A. (1999). Where is rehabilitation nursing documentation going? Rehabilitation Nursing, 24(3), 92.

   66.    Cardozo, L., & Aherns, S. (1999). Assessing the efficacy of a clinical pathway in the management of older patients hospitalized with congestive heart failure. Journal for Healthcare Quality: Promoting Excellence in Healthcare, 21(3), 12-6, 52.

   67.    Bisanz, A., DeJesus, Y., & Saddler, D. A. (1999). Development, implementation, and ongoing monitoring of pathways for the treatment of gastrointestinal cancer at a comprehensive cancer center. Gastroenterology Nursing, 22(3), 107-14.
Abstract: The purpose of this article is to explain the process used in the development and implementation of care pathways in a comprehensive cancer center in the Southwest. The pathways are a major component of the disease management process that defines a multidisciplinary standard of practice for a specific episode of care and measure outcomes as a basis for quality and cost improvement. Patients may be on several pathways as they progress through cancer treatment.   (4 ref)

   68.    Springett, J., Cowell, J., & Heaney, M. (1999). Using care pathways in pressure area management: a pilot study. Journal of Wound Care, 8(5), 227-30.
Abstract: Care pathways are a method of managing, delivering and documenting care. A pilot study of a care pathway system in pressure area management was conducted in two clinical areas. Results from this pilot study indicate that the pathway approach to pressure area management is both useful and valid as a means to enhance clinical decision-making and to facilitate comprehensive pressure area management and the completeness of care documentation. Implementation of the pathway requires a facilitator to provide support and education and to monitor and maintain the change process.

   69.    Sprague, T. E., Wren, K. R., Corpe, R. S., Philpot, T. E., Chaney, S. A., Bentz, H. L., & Bandy, L. C. (1999). Critical pathways: a means of managing the operating room. CRNA, 10(2), 65-70.
Abstract: Critical pathways help institutions in efficient and appropriate resource use to increase the quality of health care and minimize health care costs. However, many opportunities for pathway development and implementation are unexplored. This article delineates the development process for critical pathways and discusses the outcomes realized from use of the total joint pathway at the Medical College of Georgia, Augusta, GA.

   70.    Sagehorn, K. K., Russell, C. L., & Ganong, L. H. (1999). Implementation of a patient-family pathway: effects on patients and families. Clinical Nurse Specialist, 13(3), 119-22.
Abstract: The purpose of this study was to discover whether implementation of a patient-family pathway with patients and families undergoing coronary artery bypass graft (CABG) surgery impacted anxiety, information with care planning, and patient length of stay. Using an experimental design, a sample of 60 patients and family members was studied. Each patient and his or her designated family member received either the patient-family pathway or the hospital's standard care planning. Findings indicated no statistically significant differences in state anxiety or information with care planning between patients and family members receiving the patient-family pathway and those receiving standard care planning. There was no statistically significant difference in length of stay between the two patient groups. The results indicate that the CABG patient-family pathway has limited value to patients and families as measured in this study. Resources can be real-located to other uses that may have a more positive impact on the patient and family experience.

   71.    Merritt, T. A., Gold, M., & Holland, J. (1999). A critical evaluation of clinical practice guidelines in neonatal medicine: does their use improve quality and lower costs? [see comments]. Journal of Evaluation in Clinical Practice, 5(2), 169-77.
Notes: Comments: Comment in: J Eval Clin Pract 1999 May;5(2):97-101
Abstract: Clinical practice guidelines and care pathways have become a focus of quality improvement efforts in Neonatology. Health care administrators believe that using clinical practice parameters reduces health care costs, improves quality of care, and limits malpractice liability. Practice guidelines and surveys of consumer satisfaction have grown in use partly because third-party payers, insurers, and health maintenance organizations, as well as hospital administrators bent on reducing variable costs of care and contracting for capitated care have championed their development, implementation, and monitoring. Overall there is minimal evidence-based medicine to support that neonatal outcomes have benefitted from their implementation, although some studies show affirmative effects in limited populations or in a limited number of centres. For highly autonomous physicians and nurses this standardization of medical decision making may represent a difficult transition into efforts to improve quality, based on evidence-based care, and in some instances into corporate medicine. By realigning the traditional values of patient relationships, including parent involvement, the implementation of guidelines has been fast-tracked in some institutions, without appropriate audit to determine their effectiveness in achieving their goals. However, because guidelines and clinical pathways are here to stay, neonatologists need to think critically about how their content and method of implementation, monitoring and modification may influence medical and nursing teaching and decision making in the future. If guidelines are introduced primarily as a cost savings or containment tool that ignores their impact on the quality of medical care and thereby restricts needed care, then neonatologists must be quick to challenge the potentially damaging and inappropriate use of guidelines and care pathways. Several international efforts are underway to study both the impact of evidence-based guidelines and to determine if they can be imported from one care system into another. Furthermore, there are many medico-legal implications of guideline and clinical pathway implementation that may not favour physicians and other neonatal care practitioners, and leave to hospitals, insurers, and ultimately the courts, decisions regarding evidence-based care. Neonatologists and other practitioners in neonatal care centres should critically analyse the goals of guideline development, implementation and monitoring and should restrict themselves to guideline directed care only at those practices for which there is evidence supporting their implementation and continuous monitoring.

   72.    Jungkind, K., & Corish, C. (1999). Pilot acute ischemic stroke program saves $9,756 per case. Hospital Case Management, 7(5), 87-90.

   73.    Jacavone, J. B., Daniels, R. D., & Tyner, I. (1999). CNS facilitation of a cardiac surgery clinical pathway program. Clinical Nurse Specialist, 13(3), 126-32.
Abstract: In this collaborative project, the Clinical Nurse Specialist (CNS) worked with various members of the healthcare team using a clinical pathway group work process to implement changes in the nursing, medical, and respiratory care of cardiac surgery patients. The patient population (N = 598) comprised cardiac surgery patients undergoing coronary artery bypass graft, mitral valve replacement, or aortic valve replacement. The practice changes implemented were earlier extubation, earlier ambulation, the administration of fentanyl and propofol, and the administration of gastrointestinal (GI) prophylactic medications. The overall outcomes were decreased incidence of pneumonia, earlier increase in level of consciousness, improved ambulation abilities, and improved nausea levels. Pneumonia decreased significantly, from 2.49% to 1.67% (p = 0.05). For patients who met early extubation criteria, mean time on the ventilator decreased from 17 hours to 8 hours, and length of stay decreased from 8 days to 7 days in a subgroup of patients (diagnosis-related group (DRG) 105). The overall annual charge savings was approximately $201,000. These results add to the belief that CNS-guided patient care in collaboration with the healthcare team has positive benefits.

   74.    Connerney, I., Evans, D., Ange, M., Compton, O., & Bartlett, S. T. (1999). Laparoscopic nephrectomy program boosts successful outcomes at university. Inside Case Management, 6(2), 1, 6-7.

   75.    Brye, P. E., Loharikar, R., & Duda, E. (1999). New picture archiving and communications system plus new facility equals critical path planning challenge... Proccedings of the 16th Symposium for Computer Applications in Radiology. "PACS: Performance Improvement in Radiology." Houston TX, May 6-9, 1999. Journal of Digital Imaging, 12(2 Suppl 1), 130-133.
Abstract: The architectural design and construction of a new imaging department is one of the most complex challenges in healthcare architecture. When a client also plans a simultaneous change in basic operating system technology from film-based to filmless imaging, the challenge for both hospital management and the facility/technology design team is even more complicated. A purposeful planning process plus a carefully composed team of internal and external experts are the two essentials for success in executing this difficult conversion of both facility and technology. Copyright (c) 1999 by W.B. Saunders Company

   76.    Bisanz, A. (1999). Using data to enhance postoperative patient comfort and decrease costs. Oncology Nursing Forum, 26(4), 683.

   77.    Balachandran, N. (1999). 9th Chapter of Surgeons' Lecture: the orthopaedic surgeon: historical perspective, ethical considerations and the future. Annals of the Academy of Medicine, Singapore, 28(3), 336-41.
Abstract: From a fishing village with colonial surgeons from the East India Company, Singapore is now a medical and business hub servicing the region and beyond in trade and medical education. Orthopaedic Surgery is a young specialty and is the fastest growing sub-specialty in Surgery. Orthopaedic education in Singapore has a structured syllabus and training is coordinated with the Royal Colleges and the American Academy of Orthopaedic Surgeons. Part of the training as Fellows is in the United Kingdom and USA on an HMDP Fellowship. Ethics and Continuing Medical Education need further emphasis. Sub-specialisation in Orthopaedic Surgery is now well-established in Trauma, Adult Reconstructive Surgery, Sports Medicine, Spinal Surgery, Hand Surgery and Rehabilitation Medicine. Ageing in the next millennium with osteoporosis and hip fracture problems of gait and balance need more orthopaedic surgeons to be committed to rehabilitation medicine and voluntary service in the community. There is a need for good role models and knowledge on Quality Assurance, Clinical Pathways and Administration. Appropriate use of high technology and care for the aged in the community with dignity is fundamental to good ethical practice. Selfish, pecuniary interests will destroy the very soul and fabric of medicine.

   78.    Anonymous. (1999). Push past pathway limits to cut resource use. Hospital Case Management, 7(5), 84-6, 91-92.
Abstract: With lengths of stay now beginning to rebound, some experts claim that clinical pathways must be used primarily to standardize resource utilization and foster a team approach in coordinating patient care. While length of stay remains an important variable to measure, pathways don't have to be structured using a traditional time line. Other options include using a flowchart approach and supplementing traditional pathways with perioperative pathways and algorithms. To effectively identify and decrease unnecessary resource use, you must analyze what physicians and other clinicians are really using and attempt to standardize it, experts say.  (Abstract by: Author)

   79.    Anonymous. (1999). Focus on data for successful quality improvement. Data Strategies & Benchmarks, 3(5), 65-9.

   80.    Stomel, R., Grant, R., & Eagle, K. A. (1999). Lessons learned from a community hospital chest pain center. American Journal of Cardiology, 83(7), 1033-7.

   81.    Matula, P. A., & Shollenberger, D. (1999). Total joint project: acute care to home care. MEDSURG Nursing, 8(2), 92-8.
Abstract: The advent of managed care, decreased reimbursement, and competition among providers has forced acute care institutions to examine care delivery. Clinical paths provide a method that manages patient care toward positive outcomes within a cost-effective environment. A collaborative project for total joint patients beginning with the office visit and continuing through the entire episode of care is described.

   82.    Bower, K. (1999). Care along the continuum... Continuum clinical paths... part II. Curtincalls, 1(5), 9.

   83.    Anonymous. (1999). Pathways bring dramatic clinical results. Hospital Case Management, 7(4), 77-9.
Abstract: Although physicians at Good Samaritan Health System in Kearney, NE, first offered stiff resistance to case managers' efforts to implement a clinical pathway program, efforts to educate the physicians about the benefits of pathways have led to a turn-around in which physicians now are asking the director of case management to create even more pathways. One key step in promoting the pathways was to create a reporting profile capable of evaluating clinical pathways. In addition, the hospital produced a video for each pathway that describes the patient's care from preadmission through discharge. Most significantly, case managers at Good Samaritan avoided creating an adversarial relationship with physicians in the system. They dodged charges of pathways being "cookbook medicine" by establishing a system in which pathways are not automatically applied; physicians have to write an order for a patient to be placed on a pathway.  (Abstract by: Author)

   84.    Anonymous. (1999). Pathway for same-day surgery. Hospital Case Management, 7(4), 69-72.

   85.    Wilson, J. (1999). Best practice guidelines. British Journal of Nursing, 8(5), 293-4.
Abstract: Best practice guidelines and multidisciplinary pathways of care are becoming an established and essential feature of clinical practice. They can be seen in a wide variety of clinical settings ranging right across the primary, secondary and tertiary health and social care spectrums. The 1997 White Paper places strong emphasis on quality and consistency of care delivery and gives assurances of performance measurements, integrated care (Wilson, 1996) and clinical governance. It suggests making healthcare delivery against national standards a local responsibility and quality of care the driving force for decision making at every level of the service to ensure excellence for patients no matter where the care is provided. A number of controversial issues surround the use of guidelines. Some argue that they are a fetter on clinical discretion, clinical freedom and can lead to the practice of 'cookbook medicine'. Others maintain that they are an essential aid to providing safe and appropriate medical and nursing care.

   86.   Foster, L., & Moore, P. (1999). Clinical. Acute surgical wound care 4: the importance of documentation. British Journal of Nursing, 8(5), 288-92.
Abstract: This article, the last in a series of four, discusses the importance of documenting wound care. Studies have shown that nurses do not document wound care as often, or as accurately, as they should in order to comply with the UKCCs (1998) Guidelines for Records and Record Keeping. Although some wound assessment charts have been published and are in use, there is still concern about the validity or reliability of some of these charts. Studies show that further research is necessary in order to validate the charts that are currently in use. An increase in litigation has placed more emphasis on accurate record keeping which shows, in detail, the wound care that is given to each patient. Patients also want to be more informed about their treatment, and this can be done through the use of clinical pathways or multidisciplinary documents. This article also discusses the factors that have to be considered when putting a wound care chart together and gives some examples of existing charts.   (29 ref)

   87.    Foster, L., & Moore, P. (1999). Acute surgical wound care. 4: The importance of documentation. [Review] [29 refs]. British Journal of Nursing, 8(5), 288-92.
Abstract: This article, the last in a series of four, discusses the importance of documenting wound care. Studies have shown that nurses do not document wound care as often, or as accurately, as they should in order to comply with the UKCC's (1998) Guidelines for Records and Record Keeping. Although some wound assessment charts have been published and are in use, there is still concern about the validity or reliability of some of these charts. Studies show that further research is necessary in order to validate the charts that are currently in use. An increase in litigation has placed more emphasis on accurate record keeping which shows, in detail, the wound care that is given to each patient. Patients also want to be more informed about their treatment, and this can be done through the use of clinical pathways or multidisciplinary documents. This article also discusses the factors that have to be considered when putting a wound care chart together and gives some examples of existing charts. [References: 29]

   88.    Mattson, J. (1999). Case management: a historical and future perspective of its influence on outcome for persons who have sustained spinal cord injury. Topics in Spinal Cord Injury Rehabilitation, 4(4), 30-7.
Abstract: With the development of model systems in the 1970s, dedicated teams of rehabilitation professionals initiated the concept of case management. This occurred at about the same time that casualty insurers began using independent case managers. Since then, it is believed that persons with spinal cord injury (SCI) who have had the benefit of a case manager achieve and maintain better outcomes regarding health status, return to work, and modification and removal of architectural barriers. In general, these individuals have reported less depression and a more fulfilling lifestyle. The growth of managed care, with resultant abbreviated length of stay and diminished hands-on case management, may have a noticeably negative impact on adherence to clinical pathways and consequent successful outcomes. It is hypothesized that, despite technological advances, without comprehensive case management during all phases of SCI care, many individuals will not reach or maintain community reintegration and autonomy.   (12 ref)

   89.    Swain, L. M. (1999). Learning is fundamental: the impact of education on successful clinical pathway implementation. Journal for Healthcare Quality: Promoting Excellence in Healthcare, 21(2), 11-5, 48.

   90.    Bachhuber, T., & Bugryn, D. (1999). Heartworks at home. Home Healthcare Nurse Manager, 3(2), 17-23.

   91.    Spath, P. (1999). Small hospitals benefit from program investments. Hospital Case Management, 7(3), 45-8.
Abstract: Hospitals with fewer than 100 beds may find it challenging to get a return on clinical paths or case management program investments. That is why it so important to consider the hospital's managed care goals before embarking on the development of any program designed to improve care coordination. To achieve these goals, the small hospital has several different action plan choices, including: improve preadmission planning, more closely monitor the appropriateness of admissions and continued stays, expand discharge planning, design preprinted physicians' orders or protocols, expand community health services, and expand community-based case management. Most importantly, involvement is needed from physicians, managers, and staff who "own" the clinical process involved.  (Abstract by: Author)

   92.    Harlan, K., & Meiring, A. (1999). Total knee arthroplasty clinical pathway. Hospital Case Management, 7(3), 49-53.

   93.    Bower, K. (1999). Care along the continuum... Continuum clinical paths... part I. Curtincalls, 1(4), 9.

   94.    Anonymous. (1999). Flexible rehab path wins wide physician support. Hospital Case Management, 7(3), 48, 53-54, 59.
Abstract: A joint replacement pathway developed at DuBois (PA) Regional Medical Center has made fans out of patients and orthopedic surgeons like, thanks to its extremely flexible approach, which accommodates all the varying practice patterns of the referring physicians. The pathway's designer, himself a physician, devised the pathway to be so flexible because he realized that the orthopedic physicians would never be persuaded to standardize their practice patterns. Even with the designer's attempts at accommodation, many orthopedic physicians held off endorsing the pathway until patients began sharing their enthusiasm for it. The pathway has served as a useful training tool for young physical therapists.  (Abstract by: Author)

   95.    Goldman, L. (1999). The impact of hospitalists on medical education and the academic health system [see comments]. Annals of Internal Medicine, 130(4 Pt 2), 364-7.
Notes: Comments: Comment in: Ann Intern Med 1999 Oct 5;131(7):544; discussion 545, Comment in: Ann Intern Med 1999 Oct 5;131(7):544-5
Abstract: Hospitalism as a career option is likely to reinforce the emphasis of traditional medical residency programs on inpatient care; may become an alternative area of emphasis in many subspecialty fellowship programs; and may even generate its own specific types of advanced training and certification. In the academic setting, subspecialists and their trainees are concerned that hospitalists may request fewer consultations, which could adversely affect subspecialists and the education of both fellows and residents. However, the focus and expertise of hospitalists is likely to improve inpatient education for students and residents and is appealing because it has the potential to improve the quality of inpatient care. Perhaps the major effect of the hospitalist movement on academic centers will be the creation of a cadre of physicians committed to critical pathways; clinical guidelines; quality assurance; risk management; clinical re-engineering; and the use of the inpatient service as a laboratory for developing, evaluating, and implementing initiatives to improve patient care. Although any fundamental change in the organization of clinical services brings with it the risk that essential components of the current system will be jeopardized, the hospitalist movement may have great benefits if it can develop safeguards to ensure seamless patient care and the appropriate use of subspecialty expertise.

   96.    Nemeth, L. (1999). Leadership for coordinated care: role of a project manager. Critical Care Nursing Quarterly, 21(4), 50-8.
Abstract: The use of clinical pathways as a method to improve outcomes for specific populations within health care organizations has become widely adopted. This article focuses on the role of a project manager in facilitating a wide range of outcomes. Through a quality improvement framework, interdisciplinary collaboration, and data-driven decision making, organizational performance can be enhanced. An advanced practice nurse is well suited to lead organizational improvement efforts aimed at optimizing the care delivery system to effectively meet expectations of all constituents. [References: 10]

   97.    Creason, H. (1999). Tennessee case management department develops care paths for coronary artery bypass grafts. Inside Case Management, 5(11), 10-12.

   98.    Bumgarner, S. D., & Evans, M. L. (1999). Clinical care map for the ambulatory laparoscopic cholecystectomy patient. Journal of Perianesthesia Nursing, 14(1), 12-6.
Abstract: Shortened hospital stays, expectations of quick recovery, and rapid turn-around times in surgical services challenge perioperative nurses to be creative and innovative providers of essential and appropriate patient education. Nurses need approaches that enable them to meet these challenges. One such approach is the adaptation of a clinical care map to the development of a perioperative patient care guide. This article describes the rationale behind the use of this approach and its application to the education of the patient undergoing laparoscopic cholecystectomy. Steps in the process are described. Nurses can use these steps to develop patient care guides suited to their specific practice setting.

   99.    Baker, B., Fillion, B., Davitt, K., & Finnestad, L. (1999). Ambulatory surgical clinical pathway. Journal of Perianesthesia Nursing, 14 (1), 2-11.
Abstract: The purpose of this report is to describe the design, implementation, and advantages of a clinical pathway for patients undergoing ambulatory surgery. The primary purpose of the pathway is to dovetail the preoperative, intraoperative, and postoperative care of the ambulatory surgical patient. The pathway provides a mechanism to collect data and evaluate patient outcome.

100.    Dowsey, M. M., Kilgour, M. L., Santamaria, N. M., & Choong, P. F. (1999). Clinical pathways in hip and knee arthroplasty: a prospective randomised controlled study [see comments]. Medical Journal of Australia, 170(2), 59-62.
Notes: Comments: Comment in: Med J Aust 1999 Jan 18;170(2):54-5, Comment in: Med J Aust 1999 Jun 7;170(11):568, Comment in: Med J Aust 1999 Aug 16;171(4):218-9
Abstract: OBJECTIVE: To ascertain the effectiveness of clinical pathways for improving patient outcomes and decreasing lengths of stay after hip and knee arthroplasty. DESIGN AND SETTING: Twelve-month randomised prospective trial comparing patients treated through a clinical pathway with those treated by an established standard of care at a single tertiary referral university hospital. PARTICIPANTS: 163 patients (56 men and 107 women; mean age, 66 years) undergoing primary hip or knee arthroplasty, and randomly allocated to the clinical pathway (92 patients) and the control group (71 patients). MAIN OUTCOME MEASURES: Time to sitting out of bed and walking; rates of complications and readmissions; match to planned discharge destination; and length of hospital stay. RESULTS: Clinical pathway patients had a shorter mean length of stay (P = 0.011), earlier ambulation (P = 0.001), a lower readmission rate (P = 0.06) and closer matching of discharge destination. There were beneficial effects of attending patient seminars and preadmission clinics for both pathway and control patients. CONCLUSION: Clinical pathway is an effective method of improving patient outcomes and decreasing length of stay following hip and knee arthroplasty.

101.    Tyndall, P. (1999). What are guidelines and how do you work with them?.  Lippincott's Case Management, 4(1), 25-7.

102.    Crane, M., & Werber, B. (1999). Critical pathway approach to diabetic pedal infections in a multidisciplinary setting... including commentary by Lavery LA. Journal of Foot & Ankle Surgery, 38(1), 30-3, 82-3, 86-7.
Abstract: The purpose of this investigation was to evaluate, utilizing clinical and financial outcomes, the critical pathway approach to diabetic foot infections in an inpatient setting. All patients admitted with a primary diagnosis of a diabetic foot infection over an 18-month period from 1995 through 1996 were included in this retrospective study. Comparison is made between the podiatry-established critical pathway and nonpathway patient groups. Then comparison is made between these groups and a similar patient group from 1993 to confirm the validity of the overall results. There was a significant decrease in hospital stay and charges for pathway patients in 1995 and 1996 as compared to nonpathway patients in 1993 as well as 1995 and 1996 (p < .05). The authors also noted a significant decrease in major amputations (BKA or AKA) in pathway patients as compared to baseline values (1993 = 23%, 1995-1996 = 7%, p = .02) and as compared to patients not treated with this approach in 1995 and 1996 (pathway = 7%, nonpathway = 29%, p < .001). The data suggest that the use of a critical pathway approach allows earlier recognition, evaluation, and expedient treatment of potentially limb-threatening infections, improving patient outcomes by decreasing pedal morbidity, while encouraging judicious use of hospital resources.   (12 ref)

103.    Bower, K. (1999). Care along the continuum... Clinical paths: variance management tips. Curtincalls, 1(2), 9.

104.    Armstrong, C. (1999). The case manager: an advocate in and out of the workplace. Inside Case Management, 5(10), 7-9.

105.    Wilczynski, J., Cypryk, K., Zawodniak-Szalapska, M., Torzecka, W., Pertynski, T., Nadel, I., Stetkiewicz, T., Krekora, M., Sobezak, M., Jedrzejewska, E., Cyranowicz, B., Czupryniak, L., Swatko, A., Szosland, K., Drzewoski, J., Strauss, K., & Mazze, R. (1999). The role of staged diabetes management in improving diabetes care in Poland. Practical Diabetes International, 16(5), 137-141.
Abstract: Staged Diabetes Management (SDM) is a disease state management programme, that was developed by the International Diabetes Center Minneapolis, USA. Its primary aim is to achieve near-normal to normal blood glucose control in all patients with diabetes, using community involvement and simple, complete clinical pathways. SDM contains methods of diagnosis, an overview of therapy, practice guidelines, and specific detailed treatment protocols (decision paths) for type 1 and type 2 diabetes and gestational diabetes (GDM). Formal training in SDM was conducted for participating physicians and nurses, including an introduction to the philosophy and approach of SDM, provision of the materials and elucidation of the expected goals and results. After training and implementation, a series of trials were performed to determine the effectiveness of SDM in improving diabetes care in this region. The trial results evaluated the overall influence of SDM on such clinical parameters as HbA(1c) and fasting blood glucose, to assess the appropriateness of treatment modalities and timing of therapeutic choices, eg minimal delay to choice of appropriate stage. The introduction of the SDM programme led to significant reductions of HbA(1c) and fasting and postprandial blood sugar, without hypoglycaemia, in a representative group of people with type 1 diabetes. In patients with type 2 diabetes, significant reductions of HbA(1c), fasting and postprandial blood glucose without hypoglycaemia or weight-gain was achieved. To our knowledge, this is one of the first times that these goals have been achieved in people with type 1 diabetes, without hypoglycaemia, and in type 2 diabetes, without weight-gain. Using SDM we achieved 100% screening of 500 women referred for evaluation of menopausal symptoms. Approximately 5% of peri- and post-menopausal women were found to have frank diabetes (type 2) and an additional 8% had impaired glucose tolerance. Using the SDM programme, tight metabolic control in pregnant women with type 1 diabetes decreased the incidence of serious complications, eg urinary tract infections and pre-eclampsia, particularly in the critical last few weeks before delivery. We found a decrease in the incidence of serious neonatal complications in the SDM group - lower levels of: neonatal death (none seen in the SDM group); fetal congenital malformations; hypoglycaemia and respiratory distress syndrome. With respect to GDM, screening of pregnant women and proper treatment using SDM resulted in lower pregnancy and neonatal complication rates as well as fewer Caesarean sections. The success of these early pilot studies has led to a training programme that aims to introduce SDM to up to 500 primary care providers per year throughout Poland. Once trained, a larger more definitive multi-centre study of the effects of SDM will be needed to confirm the earlier findings.  [References: 13]

106.    Widimsky, J. (1999). How patients with heart failure are managed in the Czech Republic. European Journal of Heart Failure, 1(3), 305-307.

107.    Ward, R., Fidler, H., Lockyer, J., & Toews, J. (1999). Physician outcomes and implications for planning an intensive educational experience on attention-deficit hyperactivity disorder. Academic Medicine, 74(10 SUPPL.), S31-S33.

108.    Tarzian, A. J., Iwata, P. A., & Cohen, M. Z. (1999). Autologous bone marrow transplantation: The patient's perspective of information needs. Cancer Nursing, 22(2), 103-110.
Abstract: Phenomenologic inquiry was used to explore patients' experiences with autologous bone marrow transplantation (ABMT). Interviews were conducted before and after implementation of a clinical pathway that included a teaching protocol for ABMT. Texts were analyzed individually, compared for pre- and postpathway patients to determine if different themes emerged from these two groups, and then combined. Themes common to both groups included (a) a range of needs for information, (b) everybody's different: a fine balance (the challenge of finding a balance when giving information to patients who vary in the amount of information they desire), (c) someone who has been there (the value of talking to someone who has survived an ABMT), (d) and the burden of ABMT patients teaching family. One theme that reflected different experiences of pre- and postpathway patients was that of the need to know detailed information about the ABMT and the fear of knowing too much. Whereas postpathway patients reflected more on the burden of knowing too much, prepathway patients expressed more dissatisfaction about not being told enough about procedures and symptoms to be expected. Suggestions for teaching patients about ABMT include being generally realistic while focusing on the positive, and viewing patient education as a process individualized according to each patient's needs.  [References: 31]

109.    Sweeney, J. K., Heriza, C. B., Reilly, M. A., Smith, C., & VanSant, A. F. (1999). Practice guidelines for the physical therapist in the neonatal intensive care unit (NICU). Pediatric Physical Therapy, 11(3), 119-132.
Abstract: Neonatal physical therapy is an advanced practice, subspecialty area within pediatric physical therapy. Because of the structural, physiological, and behavioral vulnerabilities of neonates, pediatric physical therapists need postprofessional precepted training and experience before providing neonatal care. Theoretical frameworks, scientific basis, clinical training criteria, and a decision-making algorithm are described to guide pediatric physical therapists working in neonatal intensive care unit (NICU) settings. Clinical competencies for neonatal physical therapy practice are outlined according to roles, proficiencies, and knowledge areas. The unique role of the neonatal physical therapist is highlighted as a postural control and movement specialist within behavioral, environmental, and family contexts in the NICU. Handling infants in NICU settings is considered inappropriate for student physical therapists and physical therapist assistants and aides because each contact involves ongoing examination, interpretation, as well as multiple adjustments of procedures, interventions, and sequences to minimize risk to infants who may be potentially unstable. The guidelines are intended to provide a structure for clinical training, practitioner competency evaluation, and clinical paths for neonatal physical therapy services. A glossary of selected terminology is included in the Appendix.  [References: 24]

110.    Sheth, S. S., & Kovac, S. R. (1999). A trial of vaginal route for hysterectomy [3] (multiple letters). American Journal of Obstetrics & Gynecology, 181(1), 227-228.

111.    Sanson, B. J., Meinders, A. J., Kraaijenhagen, R. A., Van Beek, E., & Buller, H. R. (1999). Requirements for appropriate evaluation of diagnostic tests in suspected pulmonary embolism. Monaldi Archives for Chest Disease, 54(5), 417-421.
Abstract: In contrast to the development of new drugs, strict guidelines for the development of new diagnostic methods do not exist. A diagnostic test can be made available without proper evaluation of its clinical utility, which can lead to its premature introduction and inappropriate use. In this review suggestions are made regarding the criteria that should be met during the various phases of development of new diagnostic techniques. It is suggested that a new diagnostic test should only be implemented in routine clinical use after all phases of development have been properly performed with good results. Several diagnostic tests for pulmonary embolism (pulmonary angiography, ventilation-perfusion scintigraphy, D-dimer assays, and spiral computed tomography), and the studies evaluating them, are thereafter reviewed. It is concluded that present pulmonary angiography and ventilation-perfusion scintigraphy are the only properly evaluated diagnostic tests for pulmonary embolism. Although new developments, such as D-dimer assays and the spiral computed tomographic scan are certainly promising, further studies are needed to determine their real value and safety in the diagnostic work-up of patients suspected of pulmonary embolism.  [References: 49]

112.    Sado, A. S. (1999). Electronic medical record in the intensive care unit. Critical Care Clinics, 15(3), 499-522.
Abstract: The EMR in the ICU has the utility of providing the necessary information to make sound clinical decisions for critically ill patients. For it to be optimized, the EMR must be more than just what is being replicated in the written record or merely a documentation tool; it must add value that supports and enhances clinical decision support. The EMR is too expensive a tool just to be a computer designed to ease documentation and retrieve data faster. Gardner and Huff29 have suggested that the EMR must answer three questions: Why, What, and So What. The 'Why' is relatively easy to answer, but the 'What' data to use so that the information is meaningful to a provider and the 'So What' are more difficult to answer. Provided one can qualitatively assess 'What' information is important for a health care provider, then 'So What' becomes an important objective in the empirical quantification of the benefits that the EMR provides. It is clear that to analyze some of the outcomes that health care delivery provides, one needs some mechanism to automate the information at the point of care, particularly now that the regulatory agencies are requiring it. Given the fact that there is no single integrated computerized patient record, this becomes the daunting task for the next century. Making it easier for health care providers to interact with the system and providing them with instantaneous feedback that changes their medical decision so they can deliver better care (clinical pathways, clinical practice guidelines) will be the task required of the next generation of CISs.  [References: 76]

113.    Reichenspurner, H., Kur, F., Treede, H., Meiser, B. M., Deutsch, O., Welz, A., Vogelmeier, C., Schwaiblmair, M., Muller, C., Furst, H., Briegel, J., & Reichart, B. (1999). Optimization of the immunosuppressive protocol after lung transplantation. Transplantation, 68(1), 67-71.
Abstract: Background. The successful use of tacrolimus (Tac)-based immunosuppressive therapy in organ transplantation and our own positive experience in heart transplantation led us to investigate regimens including this agent at our center for lung transplantation. Methods. From 1991 to 1998, 86 patients underwent lung transplants at our center and 78 of them were included in this analysis. The first 34 patients were treated with cyclosporin (CsA), azathioprine (Aza), and rabbit antilymphocyte globulin; the subsequent 30 patients received Tac with Aza, and the most recent 12 patients Tac with mycophenolate mofetil (MMF). In addition, all patients received prednisone. Results. The number of acute rejection episodes per 100 patient days was 1.5, 0.6, and 0.3 for three treatment groups, respectively. Similarly, the incidence of refractory acute rejection per 100 patient days was lower in both Tac groups (0.20, 0.03, and 0, respectively). Freedom from acute rejection was highest in the Tac-MMF group (P=0.0037 vs. Tac/Aza, P=0.0007 vs. CsA/Aza). Freedom from recurrent acute rejection was significantly higher in both Tac groups (P=0.027 Tac/Aza vs. CsA/Aza and P=0.025 Tac/MMF vs. CsA/Aza). The incidence of infections per 100 patient days was similar (0.8, 0.5, and 0.8) in all three treatment groups, with a similar distribution of fungal, bacterial, and viral infections. Freedom from infection also showed no difference. The survival rate was significantly higher for the Tac population, with actuarial 1- and 3-year survival rates of 93% and 71%, compared with the CsA group (71% and 51%, respectively, P=0.04). Prevalence of renal dysfunction (creatinine >2.0 mg/dL) was 18%, 13%, and 0% in the 3 treatment groups, respectively. The development of glucose metabolism disorders was lower in the CsA group than in the Tac-Aza group (15% vs. 27%, P<0.05). Conclusions. Tac-based immunosuppressive therapy results in a lower rate of acute rejection after pulmonary transplantation, with similar infection rates and a slightly higher incidence of new onset diabetes mellitus compared with CsA-based therapy.  [References: 22]

114.    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. Critical Care Medicine, 27(10), 2118-2124.
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.  [References: 60]

115.    Preda, I., & Dekany, M. (1999). How the medical system manages patients with suspected or confirmed heart failure in Hungary. European Journal of Heart Failure, 1(3), 303-304.

116.    Phei Lang Chang, Ta Min Wang, Shih Tsung Huang, Ming Li Hsieh, Ke Hung= Tsui, & Rong Hau, L. a. i. (1999). Effects of implementation of 18 clinical pathways on costs and quality of care among patients undergoing urological surgery.  Journal of Urology, 161(6), 1858-1862.
Abstract: Purpose: We evaluated the effects on the costs and quality of care of implementation of 18 clinical pathways for urological operations. Materials and Methods: From April 1997 to March 1998 patients undergoing 1 of 18 urological operations were treated according to clinical pathways. The outcomes in terms of length of hospital stay and admission charges of these patients were compared with those of patients treated between April 1996 and March 1997 before clinical pathways were implemented. We also selected 7 clinically relevant quality indicators to assess the quality of care before and after clinical pathway implementation. Results: Of the 1,784 patients undergoing urological surgery from April 1997 to March 1998, 1,382 (77.5%) were treated according to 1 of the 18 clinical pathways. Before implementation 1,279 of 1,615 patients (79.2%) underwent these procedures. The length of hospital stay decreased from 5.5 to 4.9 days (p <0.01) and the average hospital admission charges decreased by 12.9% (p <0.01) after implementation. Five of the quality indicators, including the rate of surgical complications, were significantly improved after pathway implementation. The hospitalization rate was not affected (1.3 before versus 0.8% after implementation, p = 0.18). Variations clinical pathways occurred in 543 cases (39.3%) and affected the length of hospital stay only (11.6%) or the admission charge only (12.9%) more often than both (7.8%, p <0.01) or neither (7.0%, p <0.01). The most common variances in these patients were patient related (30.8%). Conclusions: Implementation of multiple clinical pathways in a urology department can improve urological practice by decreasing the length of hospital stay, admission charges and rate of surgical complications, and by improving the quality of care.  [References: 22]

117.    Papa, F. J., Aldrich, D., & Schumacker, R. E. (1999). The effects of immediate online feedback upon diagnostic performance. Academic Medicine, 74(10 SUPPL.), S16-S18.

118.    Ofulue, A. F., & Ko, M. (1999). Effects of depletion of neutrophils or macrophages on development of cigarette smoke-induced emphysema. American Journal of Physiology - Lung Cellular & Molecular Physiology, 277(1 21-1), L97-L105.
Abstract: The aim of this study was to ascertain the putative roles of neutrophils or macrophages in the pathogenesis of cigarette smoking-induced emphysema on the basis of effects of anti-neutrophil (anti-PMN) antibody or anti- monocyte/macrophage (anti-MoMac) antibody on the development of emphysema in cigarette smoke-exposed rats. Rats were treated with rabbit anti-PMN or anti- MoMac antibody and exposed 7 days/wk for 2 mo to cigarette smoke inhalation; rats treated with nonimmunized rabbit IgG (control antibody) and exposed to cigarette smoke or normal room air served as controls. Antibody treatments began 24 h before the start of smoke or air exposure and was continued with 1 treatment/wk. Total and differential cell counts in bronchoalveolar lavage fluid and collagenase-dissociated lung and determinations of the elastinolytic activity of lung neutrophils or macrophages in [3H]elastin- coated wells indicated specific suppression of neutrophil accumulation and neutrophil-related elastinolytic burden in the lungs of the anti-PMN antibody-treated smoke-exposed rats, in contrast to specific suppression of macrophage accumulation and macrophage-related elastinolytic burden in the lungs of the anti-MoMac antibody-treated smoke-exposed rats. Cigarette smoke exposure-induced lung elastin breakdown (quantitated by immunologic assay of levels of elastin-derived peptides and desmosine in lavage fluid) and emphysema in the lungs (based on morphometric analysis of alveolar mean linear intercepts and alveolar tissue density in fixed lungs) were not prevented in the lungs of anti-PMN antibody-treated smoke-exposed rats but was clearly prevented in lungs of the anti-MoMac antibody-treated smoke- exposed rats. These findings implicate macrophages rather than neutrophils as the critical pathogenic factor in cigarette smoke-induced emphysema.  [References: 37]

119.    Miller, T. W., Spicer, K., Kraus, R. F., Heister, T., & Bilyeu, J. (1999). Cost effective assessment models in providing patient-matched psychotherapy.  Journal of Contemporary Psychotherapy, 29(2), 143-154.
Abstract: Examined are various models of assessing cost-effectiveness in the use of psychological measures employed for screening patient pathology through psychological testing as a precursor to providing psychotherapy. Actual and simulated quality assurance studies are provided. The authors caution that cost-containment limited to financial incentives may have negative consequences for patient care. Systems analysis and program restructuring designed to better balance the service system through levels of care may be more clinically sound, and less costly. Clinical algorithms and critical pathways are discussed, as are recommendations that incorporate psychological testing services as an ingredient in providing contemporary psychotherapy.  [References: 13]

120.    Mercer, K. A., Chintalapudi, S. R., & Visconti, E. B. (1999). Impact of targeted antibiotic restriction on usage and cost in a community hospital. Journal of Pharmacy Technology, 15(3), 79-84.
Abstract: Objective: To determine whether antibiotic restriction can produce savings. Design: Cost comparative analysis before and after antibiotic control. Methods: Cost control policy included removal of nonessential antibiotics from the emergency department and the operating room, the use of a clinical pathway protocol for pneumonia, and approval from the infectious disease consultant for certain high-cost antibiotics. Setting: Lutheran Medical Center, a community hospital in Brooklyn, New York. Results: Between the two 12-month periods analyzed (March 1995-February 1996 vs. March 1996- February 1997), we found a cost reduction of approximately 26% among intravenous antibiotics with a concomitant 10% cost reduction in oral antibiotics. Intravenous antibiotic use decreased by more than 22%, especially with regard to higher priced agents. Furthermore, we documented a 24% reduction in cost per patient. Hospital admission rates declined only 2.5% during the second 12-month period. Conclusions: Appropriate restriction of antibiotics can be done effectively and simply in a local hospital with no additional funding and achieve considerable cost savings.  [References: 20]

121.    Medina, E. M. (1999). Project programming to start-up. Pharmaceutical Engineering, 19(4), 62-69.
Abstract: This article presents a streamlined method for managing projects as they evolve. It will show the steps, attributes and criteria that should be observed in programming projects. A flow chart summarizing the critical path is provided as a process guide.  [References: 3]

122.    Mears, E. (1999). Linking serum prealbumin measurements to managing a malnutrition clinical pathway. Journal of Clinical Ligand Assay, 22(3), 296-303.
Abstract: When malnutrition is identified and treated early, hospital stay and costs are reduced. Length of stay is an appropriate measure of patient outcome because it is clearly associated with the patient's hospital course and is affected by the patient's nutrition status. The information can be easily determined from the patient record and can also be measured in financial terms. Several hospitals have selected prealbumin over albumin as a screening/monitoring tool to allow accurate identification of cases at risk. It may not be possible for all institutions to carry out daily prealbumin measurements, but a systematic and multi-disciplinary approach to screening and monitoring can be devised. Now that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandates screening as part of routine patient care, the development of practice guidelines offers an opportunity to achieve compliance as well as improve quality of care.  [References: 45]

123.    Marrie, T. J., Lau, C. Y., Weeler, S. L., Wong, C. J., Vandervoort, M. K., & Feagan, B. G. (1999). A critical pathway for the treatment of community-acquired pneumonia. Drugs, 58(SUPPL. 2), 273-275.

124.    Marazziti, D., Dell'Osso, L., Presta, S., Pfanner, C., Rossi, A., Masala, I., Baroni, S., Giannaccini, G., Lucacchini, A., & Cassano, G. B. (1999). Platelet [3H]paroxetine binding in patients with OCD-related disorders. Psychiatry Research, 89(3), 223-228.
Abstract: The recently introduced notion of clinical conditions being related one to another, the spectrum concept, permits the testing of the involvement of serotonergic systems in a broad range of disorders tentatively linked to obsessive-compulsive disorder (OCD) for which no pathophysiological hypotheses yet exist. We therefore compared the binding of [3H]paroxetine ([3H]Par), a ligand that specifically labels the serotonin (5-HT) transporter, in platelets of drug-free outpatients suffering from various OCD-related disorders with binding in platelets of OCD patients and healthy subjects. Diagnoses were made according to DSM-IV criteria. The most frequent diagnosis was that of body dysmorphic disorder, followed by impulse control disorder, kleptomania, Tourette's syndrome and trichotillomania. Platelet membranes and [3H]Par binding were studied according to standardized protocols. The results, showing a similarly decreased density of [3H]Par binding sites in both patient groups as compared with healthy subjects, suggest the presence of a shared abnormality at the level of the presynaptic 5-HT transporter, probably linked to a common dimension yet to be identified. Copyright (C) 1999 Elsevier Science Ireland Ltd.  [References: 34]

125.    Lumb, P. D. (1999). The financial prerogatives of excellence. Seminars in Anesthesia, 18(3), 242-253.
Abstract: Critical care anesthesiology's active participation in peroperative care of the elective surgical patient has never been more important or timely. Irrespective of the financial model, the elective surgical schedule provides institutions with the process-rich environment amenable to change and efficiency augmentation. Postoperative care of those patients requiring sophisticated monitoring and active management of emergence, with its attendant physiological disturbances, requires the presence of physicians trained to recognize deviations from anticipated recovery and capable of intervening rapidly to ensure a satisfactory outcome that follows a predictable course. The greatest difficulty in accomplishing this practice and professional organizational and therapeutic goal lies in specialty overcoming specialty prejudice and bias. 'The ancient masters didn't try to educate the people, but kindly taught them to not-known. When they think that they know the answers, people are difficult to guide/When they know that they don't know, people can find their own way.' The opportunity to develop multidisciplinary and mutually supportive care plans that include all aspects of peroperative process flow requires institutional commitment and resource allocation. Equally, it requires sensitivity and diplomacy from all physicians, nurses, and ancillary support employees involved in the discussions. Unfortunately, many people believe that they will appear smarter to their bosses if they are more critical - and it often works. In many organizations, it is professionally rewarding to react critically to new ideas. Unfortunately, this sort of negativity bias can have severe consequences for the creativity of those being evaluated....a culture of evaluation leads people to focus on the external rewards and punishments associated with their output...creates a climate of fear...and shows up in how managers treat people whose ideas don't pan out; often they are terminated or otherwise warehoused within the organization. Critical care anesthesiologists who seek leadership responsibility in this arena must understand their local institutional culture and be willing to accept responsibility for its change. I'm not going to tell you that all employees at Continental are 'empowered'. We fly airplanes, after all. When people's lives are at stake, certain rules and procedures are not open to interpretation or re-invention on a daily basis. Now, fun at work isn't about dancing on the tarmac. In fact, I think the word fun scares a lot of executives. They picture productivity plummeting and profits along with it. But I would argue that people have fun at work when they are engaged, when their opinions are respected. People are happy when they feel they are making a difference. A leader's responsibility is to create the context in which change can be successful while preserving the integrity of the profession and redefining and enhancing its prerogatives. Unfortunately, 'we subconsciously decide what to do before figuring out why we want to do it .... When it comes to business decisions, there's rarely such a thing as a no-brainer. Taking action to understand and avoid psychological traps - in isolation or in combination-is awareness.' Physicians must learn the rigors of the corporate world in which personal prerogative is appropriately evaluated with respect to the institutional good. We join spokes together in a wheel, but it is the center hole that makes the wagon move. We shape clay into a pot, but it is the emptiness inside that holds whatever we want. We hammer wood for a house, but it is the inner space that makes it livable. We work with being' but non- being is what we use. Lao-tzu summarizes eloquently the challenges facing critical care anesthesiologists; it remains for us to accept the responsibility to succeed. [References: 27]

126.    Ludwig-Beymer, P., & Greene, A. B. Jr. (1999). Advocate Health Care's approach to adult asthma. Chest, 116(4 SUPPL. 1), 206S-207S.

127.    Lee, J. H., Swain, B., Andrey, J., Murrell, H. K., & Geha, A. S. (1999). Fast track recovery of elderly coronary bypass surgery patients. Annals of Thoracic Surgery, 68(2), 437-441.
Abstract: Background. To ascertain whether early extubation and fast-track treatment protocols are feasible in elderly patients, we analyzed 487 consecutive patients who had isolated coronary artery bypass grafting between January 1995 and June 1997, constituting the experience of a single surgeon. Methods. Management consistently applied to all patients emphasized early extubation protocol, tepid cardioplegia and normothermic bypass to reduce pump times, early mobilization and chest tube removal, and protocol treatment of atrial fibrillation. Elderly patients at least 70 years old (n = 176, mean age 75 years) were compared with younger patients (n = 311, mean age 58 years). Results. The hospital mortality rate was 0.8% (4 of 487 patients), and there was no difference in the operative mortality rate of the older cohort versus the younger cohort (0.6% versus 0.9%; p > 0.05). Older patients had a higher incidence of peripheral vascular disease, congestive heart failure, prior strokes, renal failure, and cerebrovascular disease (p < 0.05). Early extubation was achieved in 71% of younger patients versus 57% of older cohort (95% confidence interval, 14% +/- 9%; p = 0.002). Older patients had significantly higher incidence of postoperative atrial fibrillation (27% versus 14%; 95% CI, 13% +/- 7%; p < 0.001), a factor responsible for shorter length of stay among younger patients (5.6 +/- 2.8 days versus 7.2 +/- 3.7 days; 95% CI, 1.6 +/- 0.3 days; p < 0.001). Nonetheless discharge before the fifth postoperative day was achieved in 34% of the elderly patients. Conclusions. Although elderly patients have a higher acuity of illness, critical pathways for accelerated discharge are safe and feasible in most elderly patients.  [References: 18]

128.    Lee, A. G., & Dutton, J. J. (1999). A practice pathway for the management of gliomas of the anterior visual pathway: An update and an evidence-based approach. Neuro-Ophthalmology, 22(3), 139-155.
Abstract: Purpose: To propose a practice pathway based upon the available medical literature for the management of optic pathway gliomas. Methods: A computerized Medline search of the English language literature on optic pathway gliomas from 1966 to 1998 was made. A practice pathway for the management of these tumors was developed based upon the available evidence. Results: The results of the practice pathway are summarized in an easy-to-follow, user-friendly treatment algorithm. Conclusion: The treatment of optic pathway gliomas is controversial. The use of an evidence-based practice pathway may assist the clinician in the management of these difficult cases.  [References: 259]

129.    Le Paillier, R., & Varlan, E. (1999). Optimal computerized management of developments for pharmaceutical companies. Clinical Research & Regulatory Affairs, 16(3), 71-90.
Abstract: The choice of the optimal project for product development until the registration, is fundamental for best management results (better, faster and cheaper) of the various departments in a pharmaceutical company. The methodology of decision analysis rationale presented in this work is based upon data to estimate the probability of realizing projects. This is done by comparing the real versus the anticipated project by using schedule-plans during the process. This method is illustrated by describing computerized systems to manage tasks in a clinical development with GANTT diagrams and PERT networks. These computerized systems to estimate the full duration of a project and help to determine the critical path to take. In this example, the project presented can correspond to the full development of drugs or medical devices, from the preclinical phases through the registration, without forgetting phase 4 (post-marketing phase).  [References: 40]

130.    Krieff, D., Kaplan, J., Mungall, D. R., Treadwell, P., Wasserman, W., Seibold, J., Blair, G., Krasinski, K., Watson, D., & Norsworthy, H. C. (1999). Community-acquired pneumonia: Approaches within managed care. American Journal of Managed Care, 5(9 SUPPL.), S539-S554.
Abstract: Disease management plans used by 8 different institutions to improve outcomes in the treatment of community-acquired pneumonia (CAP) are discussed. The first case study reviews the development of a clinical pathway using levofloxacin, one of the newer fluoroquinolones, for the treatment of patients hospitalized with CAP. In the second case study, an approach that identifies patients who would benefit from early conversion from intravenous to oral levofloxacin is developed. In the third study, the development of a cost containment plan and a drug utilization evaluation to optimize the use of fluoroquinolones in the treatment of patients with CAP are reviewed.  [References: 22]

131.   Koyama, T., Okudera, H., Gibo, H., & Kobayashi, S. (1999). Computer-generated microsurgical anatomy of the basilar artery bifurcation. Technical note. Journal of Neurosurgery, 91(1), 145-152.
Abstract: The authors' goal was to develop a computer graphics model to represent the microsurgical anatomy of the basilar artery (BA) bifurcation and surrounding structures to simulate surgery of a BA bifurcation aneurysm performed via the transsylvian approach. The source of the input data was a variety of publications that showed detailed anatomy of the area. A computer graphics model of the area near the BA bifurcation including relevant structures, such as perforating branches or cranial nerves, was depicted in detail. A BA bifurcation aneurysm was added to the computer graphics model and it was rotated to simulate the transsylvian approach. After the internal carotid artery was displaced using a virtual retractor, the aneurysm was exposed, thus providing an understanding of the three-dimensional surgical orientation of the area. Designing a standard anatomical model on the basis of data culled from a variety of publications and adding morphological changes by using a virtual retractor to displace structures that obstruct the view along a critical path at the base of the brain are useful strategies of computer manipulation for surgical simulation in open microneurosurgery. This methodological tool would be useful in teaching surgical microanatomy and in introducing a new navigational system for virtual reality. Both concept and technical details are discussed.  [References: 31]

132.    Klock, P. A. Jr, & Ellis, J. E. (1999). Clinical pathways for vascular anesthesia and surgery. Problems in Anesthesia, 11(2), 224-237.
Abstract: Clinical pathways have become increasingly popular. Pathway goals and tips for successful development and implementation are discussed. Finally, specific examples of clinical pathways in the perioperative care of vascular surgery patients are reviewed.  [References: 47]

133.   Indritz, M. E. S., & Artz, M. (1999). When cost is a consideration: Using decision analysis for formulary recommendations. P & T, 24(8), 368-382.
Abstract: Decision analysis is a tool that organizes existing information, incorporates new information on effectiveness and outcomes, and structures information to help clarify choices. It is easily applied to healthcare situations, particularly when developing critical pathways and making decisions regarding formularies. The following article reviews the decision analysis process to determine the best pharmacoeconomic selection of a drug for formulary addition, taking both therapeutic and cost considerations into account. The authors outline a step by step method that others can use to evaluate comparative drugs and their associated cost effectiveness.  [References: 24]

134.    Home, P. (1999). A desktop guide to Type 1 (insulin-dependent) diabetes mellitus. Diabetic Medicine, 16(3), 253-266.

135.    Hanly, C. (1999). On subjectivity and objectivity in psychoanalysis. Journal of the American Psychoanalytic Association, 47(2), 427-44.
Abstract: Epistemological subjectivism has found its way into psychoanalysis along several theoretical and clinical paths. It has developed out of the clinical interest in transference and countertransference and, in particular, from the broadly generalized definition of countertransference now popular. The clinically necessary attention to analyst-analysand interaction has been turned into interactionism or intersubjectivism and a denial of epistemological subject-object differentiation. These perspectives transform a clinical focus on the here and now of the analytic relation into the determination of the past by the present and a teleological reversal of causality. Once this reversal is made, narrative in the analytic situation becomes the co-creation of the analysand's past by the present analyst-analysand relation. Psychoanalysis, on this view, can at best substitute a coherent, novelistic account for the life history of a person. Some of the problems of subjectivism are examined here with a view to restoring to psychoanalysis the epistemology of science and common sense.

136.    Guidetti, D. (1999). Considerations on the evolution of the DRG based prospective payment system. Rivista Di Neurobiologia, 45(2), 193-200.

137.    Glenn, D. M., & Macario, A. (1999). Do clinical pathways improve efficiency? Seminars in Anesthesia, 18(4), 281-288.

138.    Ghotbi, M., & Ramsay, J. (1999). The economics of cardiac fast tracking. Seminars in Cardiothoracic & Vascular Anesthesia, 3(4), 242-247.
Abstract: Extubation within a few hours of cardiac surgery is possible in the majority of patients and is not associated with an increased risk for perioperative complications. Duration of intubation is an important factor in overall postoperative length of stay, and when early extubation is instituted as part of a comprehensive clinical pathway, it contributes to significant reductions in both intensive care unit and hospital length of stay. In association with reductions in direct variable costs, these reductions in length of stay have been shown in several studies to significantly reduce overall cost or charge.  [References: 30]

139.    Gelinas, D. (1999). Conceptual approach to diagnostic delay in ALS: a United States perspective. Neurology, 53(8 Suppl 5), S17-9; discussion S20-1.
Abstract: The mean time from onset of symptoms to confirmation of diagnosis of amyotrophic lateral sclerosis (ALS) in the United States, as elsewhere, is 16-18 months. Delays may arise from the complex referral pathway, caused at least in part by the multiple types of insurance and health-care services available in the United States and also because physicians sometimes attempt to avoid medicolegal responsibility for a very undesirable diagnosis. In addition, initial symptoms are often intermittent and nonspecific and may be denied or not recognized by the patient. In the United States, the primary care physician is increasingly viewed by health maintenance organizations as a gatekeeper, with incentives to keep the diagnosis within the primary care realm. This may lead to misdiagnosis and inappropriate referral. Even after the patient reaches a neurologist, the differential diagnosis of ALS is large and may involve many tests, all of which may incur scheduling and reporting delays. Reluctance to give a bad diagnosis before it is absolutely certain may also cause delay. Delays after diagnosis may be the result of health insurance constraints, the prejudices of the neurologist in favor of or against particular therapies, and the patient's willingness to accept or ability to pay for therapy. Many of these delays may be lessened by both professional and lay educational initiatives to raise awareness of the symptoms of ALS and encourage more rapid presentation and referral to the neurologist. The availability of credible treatment options would undoubtedly encourage physicians to have hope and to seek an earlier diagnosis. [References: 0]

140.    Firilas, A. M., Higginbotham, P. H., Johnson, D. D., Jackson, R. J., Wagner, C. W., & Smith, S. D. (1999). A new economic benchmark for surgical treatment of appendicitis. American Surgeon, 65(8), 769-773.
Abstract: Cost reduction in the management of common surgical diseases such as appendicitis has become paramount for the survival of children's hospitals. We designed a clinical pathway to treat appendicitis with the goal of reducing cost and hospital length of stay (LOS) while maintaining quality of care. From September 1995 through December 1996, patients with nonperforated appendicitis (NPApp) and perforated appendicitis with peritonitis (PApp) were enrolled into a clinical pathway. NPApp patients were discharged when tolerating a regular diet. PApp patients were discharged if the following criteria were met: temperature < 38.5 [degree] C for 24 hours, WBC < 14,000 on postoperative day 3, tolerating diet, and transition to oral analgesics accomplished. Hospital LOS and actual hospital costs in pathway patients were compared with those of historic controls. Patients with appendicitis from the Pediatric Health Information Systems (PHIS) database, a consortium of 20 children's hospitals in the United States, served as concurrent controls. Hospital LOS and hospital charges in PHIS NPApp and PApp patients from our institution were compared with national PHIS database patients. Mean LOS and hospital costs for both NPApp and PApp pathway patients were significantly decreased compared with historic controls (P < 0.05). Mean LOS and hospital charges in our institution's PHIS NPApp and PApp patients were also significantly decreased compared with the national PHIS database (P < 0.05). Innovative approaches such as these are necessary for the survival of children's hospitals in an increasingly cost competitive healthcare market.  [References: 12]

141.    Dubrovsky, A. L., & Sica, R. E. (1999). Current treatment pathways in ALS: a South American perspective. Neurology, 53(8 Suppl 5), S11-6.
Abstract: This article presents the findings relating to the South American subgroup of 60 patients in an international survey of the current diagnosis and treatment of patients with amyotrophic lateral sclerosis (ALS). The mean time between first symptoms and first consultation with a physician was 3.7 months, and mean delay in seeing a neurologist was then 5.6 months, giving a mean time from symptom onset to confirmation of diagnosis of 16.6 months. The time to confirmation of diagnosis was much longer for patients with symptoms of limb onset (17.5 months) than for those with bulbar onset (10.0 months). Cases with symptoms of upper-limb onset were diagnosed more rapidly (14.9 months) than those with symptoms of lower-limb onset (21.8 months). The diagnosis was confirmed in 48% of cases within 15 months of symptom onset, and a further 27% were diagnosed within 15-24 months; 47% of cases were confirmed within 4 months of consulation with a neurologist and a further 17% within 4-6 months. The first physician seen was the general practitioner in 47% of cases overall. When the neurologist was the first physician seen (27% of patients in Brazil, 0% in Argentina), diagnosis was achieved within 14 months in 88% of cases. EMG was performed in almost all patients. MRI and CT were widely used, which may cause delays. Announcement of the diagnosis was made immediately to 75% of patients overall. Riluzole was prescribed for 23% of patients in Brazil and for 67% of patients in Argentina.

142.    Dhanasekaran, N., Wu, Y. K., & Reece, E. A. (1999). Signaling pathways and diabetic embryopathy. Seminars In Reproductive Endocrinology, 17(2), 167-74.
Abstract: Diabetic embryopathy is the leading cause of neonatal death and/or congenital malformations in infants of diabetic mothers. Because the development of the embryo critically depends on the maternal and the embryonic signaling pathways, a defective signaling mechanism between the maternal and the embryonic tissues appears to be involved in the etiology of diabetic embryopathy. Analyses of the recent studies from different laboratories suggest a "multifactorial" basis for diabetic embryopathy. These studies suggest that a wide variety of signal-transducers converge towards the regulation of elcosanoid signaling pathway which appears to be the critical pathway involved in diabetic embryopathy. The characterization of the regulatory components of this pathway is likely to identify the signaling loci susceptible for the therapeutic intervention.

143.    DeSwarte-Wallace, J., Groncy, P. K., & Finklestein, J. Z. (1999). Iron chelation with deferoxamine: Comparing the results of a critical pathway to a national survey. Journal of Pediatric Hematology Oncology, 21(2), 136-141.
Abstract: Purpose: The clinical outcomes of an institution's critical pathway that uses a comprehensive approach to serum ferritin management are reported. The results of this center are compared with the results of a national survey of deferoxamine (DFO) use and serum ferritin level outcomes. Methods: Current DFO dosing and serum ferritin levels of 38 patients at this center were summarized. A questionnaire was then sent to 98 centers throughout the United States requesting information on criteria for beginning treatment with DFO, administration methods, dose modifications, and serum ferritin levels. Results: The application of a critical pathway in this program resulted in 29 of 38 patients maintaining serum ferritin levels <2,000 ng/mL. Of the 42 institutions that responded to the survey, 10 attained this ferritin level in >=50% of their patients. Ferritin levels ranged from 500 ng/mL to >20,000 ng/mL, and wide variations were reported in all study parameters. Conclusions: Iron overload can be effectively managed with alteration of DFO doses and routes using a consistent approach. Modification of administration methods, including administration of DFO during red blood cell transfusions, are indicated to attain ferritin levels of <2,000 ng/mL.  [References: 22]

144.    Dengler, R. (1999). Current treatment pathways in ALS: a European perspective. Neurology, 53(8 Suppl 5), S4-10; discussion S20-1.
Abstract: This article presents the findings relating to the European subgroup of 91 patients in an international survey of the current diagnosis and treatment of patients with amyotrophic lateral sclerosis (ALS). The mean time between first symptoms and first consultation with a physician was 4.9 months, and mean delay in seeing a neurologist was then about 6 months, yielding a mean time from symptom onset to confirmation of diagnosis of 17.8 months. The time to confirmation of diagnosis was slightly longer for patients with symptoms of limb onset (18.5 months) than for those with bulbar onset (17.5 months). Cases with symptoms of upper-limb onset were diagnosed more rapidly (15.5 months) than those with symptoms of lower-limb onset (21.8 months). The diagnosis was confirmed in 51% of cases within 15 months of symptom onset, and a further 23% were diagnosed within 15-24 months; 55% of cases were confirmed within 4 months of consultation with a neurologist, and a further 14% within 4-6 months. The first physician seen was the general practitioner in 68% of cases. When the neurologist was the first physician seen (7% in Germany, 13% in Italy, 0% in Spain), diagnosis was achieved within 14 months in 67% of cases. EMG was performed in almost all patients. MRI and CT were widely used, possibly causing delays. Announcement of the diagnosis was made immediately to 85% of patients and within 1 month to a further 9%. Riluzole was prescribed for 76% of patients overall.

145.    Crippen, D. (1999). Critical care and the Internet: A clinician's perspective. Critical Care Clinics, 15(3), 605-614.
Abstract: The Internet holds great promise for clinicians because of its ability to access and consolidate large amounts of knowledge quickly and easily. As a result, information overload is occurring and physician users are finding it necessary to use creative and selective methods to digest this data. Physician users will have to discover new skills to determine authenticity and substance of data as they sift through mountains of coal looking for diamonds. Users will become an integral part of the evolution process, guiding the Internet towards merit and magnitude.  [References: 25]

146.    Correa, A. J., Reinisch, L., Paty, V. A., Sanders, D. L., & Duncavage, J. A. (1999). Analysis of a critical pathway in osteoplastic flap for frontal sinus obliteration. Laryngoscope, 109(8), 1212-1216.
Abstract: Objectives: A critical pathway was applied to patients undergoing osteoplastic flap (OPF) for frontal sinus obliteration to determine whether efficiency could be improved. Study Design: A retrospective review of consecutive OPF procedures (n = 51) performed between 1992 and July 1997 was conducted. Methods: The patient groups were subdivided into those who underwent OPF alone and those who had endoscopic sinus procedures performed in addition to OPF. Comparisons were made between the precritical pathway and post-critical pathway groups, specifically noting operative time, total operating room (OR) time, estimated blood loss (EBL), length of hospital stay, and costs. We used a critical pathway that was developed for endoscopic sinus procedures at our institution through a multidisciplinary team approach. Preoperative evaluation and testing, intraoperative equipment and medications, and postoperative care including follow-up clinic visits were all standardized. An unpaired, two-tailed Student t test was used to evaluate the data. Results: Statistically significant (P < .05) reductions in operative times, total OR time, EBL, and length of hospital stay were observed in the post-critical pathway group who underwent endoscopic sinus procedures as well as OPF. Costs to the OR were reduced 29% and 15% for OPF and for OPF with endoscopic surgery, respectively. Patient costs were reduced 5% and 4% in these groups, respectively. Conclusions: With implementation of effective critical pathways, significant decreases in length of stay are seen, and cost reductions can be realized through the improved efficiency, shortened OR times, and decreases in redundancy of ordering materials.  [References: 8]

147.    Colquhoun, M. (1999). What's new in resuscitation guidelines? (Single rescuer adult) basic life support. British Journal of Cardiology, 6(7), 398-402.

148.    Cannon, C. P., Sayah, A. J., & Walls, R. M. (1999). Prehospital thrombolysis: An idea whose time has come. Clinical Cardiology, 22(8 SUPPL.), IV-10-IV-19.
Abstract: Aggressive reperfusion therapy for myocardial infarction (MI) characterized by acute ST-segment elevation leads to improved patient outcome. Furthermore, use of thrombolytic therapy is highly time-dependent: reperfusion therapy is beneficial within 12 h, but the earlier it is administered, the more beneficial it is. Thus, the focus of both prehospital and emergency department management of patients with acute MI is on rapid identification and treatment. There are many components to the time delays between the onset of symptoms of acute MI and the achievement of reperfusion in the occluded infarct-related artery. Time delays occur with both the patient and the prehospital emergency medical system, although patient delays are more significant. This article focuses on the prehospital management of acute MI, including (1) the rationale for rapid reperfusion in patients with acute MI, (2) the factors related to time delays in patient presentation to the hospital, and (3) strategies for reducing time delays, both patient- and medical system-based.  [References: 75]

149.    Brooks, B. R. (1999). Defining optimal management in ALS: from first symptoms to announcement. Neurology, 53(8 Suppl 5), S1-3; discussion S20-1.
Abstract: The advances in treatment for amyotrophic lateral sclerosis (ALS) have demonstrated the need to diagnose this disease precisely and directly. Two international initiatives, at El Escorial in 1990 and at Airlie House in 1998, have grappled with the clinical and laboratory elements that may accelerate the diagnostic process. Shortly after the Airlie House meeting in 1998, an international group of clinical neurologists met to discuss optimal management strategies in ALS. The goals were to examine current diagnosis and treatment pathways and to attempt to devise an algorithm that would foster early diagnosis, thus enhancing the possibility of optimal treatment. [References: 3]

150.    Braun, J. S., Novak, R., Gao, G., Murray, P. J., & Shenep, J. L. (1999). Pneumolysin, a protein toxin of Streptococcus pneumoniae, induces nitric oxide production from macrophages. Infection & Immunity, 67(8), 3750-3756.
Abstract: Nitric oxide (NO) production by inducible NO synthase (iNOS) during inflammation is an essential element of antimicrobial immunity but can also contribute to host-induced tissue damage. Under conditions of bacterial sepsis, large amounts of NO are produced, causing hypotension, a critical pathological feature of septic shock. In sepsis caused by gram-positive organisms, the bacterial factors contributing to host NO production are poorly characterized. We show that a soluble toxin of Streptococcus pneumoniae, pneumolysin (Pln), is a key component initiating NO production from macrophages. In contrast to wild-type bacteria, a mutant of S. pneumoniae lacking Pln failed to elicit NO production from murine macrophages. Purified recombinant Pln induced NO production at low concentrations and independently of exogenous gamma interferon (IFN-gamma) priming of RAW 264.7 macrophages. However, IFN-gamma was essential for Pln- induced NO production, since primary macrophages from mice lacking the IFN- gamma receptor or interferon regulatory factor 1, a transcription factor essential for iNOS expression, failed to produce NO when stimulated with Pln. In addition, Pln acts as an agonist of tumor necrosis factor alpha and interleukin 6 production in macrophages. The properties of Pln, previously identified as a pore-forming hemolysin, also include a role as a general inflammatory agonist.  [References: 41]

151.    Baker, E. A., Connell, K. J., Bordage, G., & Sinacore, J. (1999). Can diagnostic semantic competence be assessed from the medical record? Academic Medicine, 74(10 SUPPL.), S13-S15.

152.    Baker, A. M., Arnold, R. J. G., & Kaniecki, D. J. (1999). Economic analysis in clinical trials: Practical considerations. Drug Information Journal, 33(4), 1053-1060.
Abstract: The article addresses several important issues in the measurement of medical resource utilization or direct medical costs when incorporating such measurements into clinical trials. One of the most important issues faced by the analyst relates to the high internal validity of randomized, controlled trials, which require protocol-driven experiences that may falsely increase or decrease costs. The technique of modeling, which will require judgments on the level of detail to include in clinical pathways, can be employed in the identification of costs. Other important issues include attribution of costs to disease or treatment and assignment of monetary values. Sources of cost data, reimbursement coding systems, and resource valuation data sources in the United States are described. Finally, the trade-offs inherent in including economic evaluations in Phase III clinical trials are addressed and specific guidelines for performing economic evaluations in clinical trials are provided.  [References: 21]

153.    Awad, I. A., Fayad, P., & Abdulrauf, S. I. (1999). Protocols and critical pathways for stroke care. Clinical Neurosurgery., 45, 86-100.
Abstract: We have presented a conceptual approach toward developing clinical protocols and critical pathways in a complex multidisciplinary environment with a commitment to clinical excellence, evidence-based practice methodology, and education. The process and the mood surrounding these have been more important in our view than any particular protocol or pathway. They have generated an attitude aiming toward avoidance of complications rather than crisis management. They have contributed to a philosophy of integrative multidisciplinary collaborations among various specialists, house staff, and nursing and paramedical personnel and a greater mutual sensitivity in interactions with medical center management and administration. The overall impact of this global approach has been quantifiable (Fig. 6), although the role(s) of one or more facets of it cannot be independently defined (21, 22). Protocols and clinical pathways should be viewed as components of total quality management. They should not be allowed to restrict the patient's or physician's choice of interventions, they should not inhibit in any way innovation or the introduction of novel methodologies. Yet, protocols and critical pathways should and do generate a pressure on every member of the health-care team, a sense of negative entropy constantly urging a move toward a higher level of excellence and quality. [References: 26]

154.    Abraham, W. T. (1999). Preceptorships: A practical approach to education in heart failure. Journal of Cardiac Failure, 5(3), 265-268.
Abstract: Heart failure is increasing in incidence and prevalence and is associated with significant morbidity and mortality (1-3). The heart failure center, although well equipped to handle more complex cases of moderate to severe heart failure, cannot accommodate all heart failure cases. Because the majority of heart failure patients are, and should be, treated at the primary care level, the heart failure center can have an important role in both disseminating information on state-of-the-art care and creating a partnership between the center and the community physician. Thus, preceptorships may be an excellent tool for enabling physicians to increase their depth of knowledge about optimal treatment strategies and develop stronger relationships with regional and local physicians who specialize in heart failure management. In turn, referral networks will be strengthened and the likelihood of appropriate consultations increased. Finally, closer interaction with experts in heart failure may help clinicians in the community be aware of clinical trials suitable for their own patients. An excellent setting for sharing ideas and strategies, the preceptorship should be a comfortable training environment for most physicians. When group size is small, participants can work with preceptors to individualize the experience by identifying subject matter in which they have the most interest. First- hand observation of functional heart failure teams may enhance participants' comfort with a team approach and may provide a referral base for ancillary services, such as dietary counseling or patient education. Based on the experience at the University of Cincinnati, preceptorships are an excellent way to disseminate and encourage the adoption of standards for the prevention, diagnosis, and management of heart failure. The program also permits us to advise participants on developing their own heart failure practice and establish criteria and critical pathways for patient referrals. Preceptorships provide a unique opportunity to share with practicing physicians many of the advances that have occurred in heart failure management while clarifying and distilling the finer points of patient management into easy, memorable, and practical approaches.  [References: 16]

155.    Gibb, H. (1998). Reform in public health: where does it take nursing? Nursing Inquiry, 5(4), 258-67.
Abstract: The Australian healthcare system is undergoing changes that are impacting tangibly on professional nursing practice. While the evidence is clear that the changes pose a challenge to maintaining standards amidst resource cuts and restructuring, the processes through which these changes occur and the decisions which drive the reforms remain complex and largely obscure. This paper intends to stimulate further thinking and debate among nurses about the effects of these reforms on the conduct of practice, both in terms of our emerging discipline and our ability to conduct clinical nursing practice. It offers a way of understanding the policy 'reform' process through an application of policy analysis grounded in critical social theory. The discussion sets out to apply these analytical propositions to specific events that constitute examples of change in the nursing workplace, and to focus on the implications for nurses and health service clientele. [References: 51]

156.    Barnes, L. (1998). 'Mission impossible': musings on a postgraduate research project. Nursing Inquiry, 5(4), 285-6.

157.    Eisenberg, A. A., & Redick, E. L. (1998). Transsphenoidal resection of pituitary adenoma: using a critical pathway. Dimensions of Critical Care Nursing, 17(6), 306-12.
Abstract: The use of a transsphenoidal critical pathway can be a vital tool for critical care nurses in anticipating complications and improving patient outcomes. Complications such as diabetes insipidus and cerebrospinal fluid leak associated with posttranssphenoidal patients may result in prolonged hospitalization and worsened functional outcome. Implementing a transsphenoidal critical pathway for these patients can guide their care and alert critical care nurses to potential complications and their prevention and/or treatment. [References: 6]

158.    Tovar, E. A. (1998). Minimally invasive approach for pneumonectomy culminating in an outpatient procedure. Chest, 114(5), 1454-8.
Abstract: STUDY OBJECTIVE: To establish the effects of the use of a clinical pathway that includes a minimally invasive access among patients undergoing pneumonectomy. DESIGN: Prospective study from February to December of 1997. SETTING: A community hospital. PATIENTS: Five consecutive patients with a mean age of 60 years (range 43 to 74 years) with lung malignancies who required pneumonectomy. INTERVENTIONS: Clinical pathway based on patient education, a meticulous minimally invasive operation (oblique muscle-sparing minithoracotomy), intercostal nerve cryoanalgesia, and a quick postoperative resumption of physical activity. RESULTS: All five patients were extubated in the operating room. They all had unrestricted shoulder mobility in the recovery room, and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation, and one patient was able to ambulate freely only a few hours after the procedure. Four patients were discharged the day after surgery, and one patient was discharged the same day of the operation. None required readmission related to the procedure. CONCLUSION: This initial experience seems to indicate that the application of this clinical pathway in patients undergoing pneumonectomy greatly accelerates their recovery and, for a select group of patients, converts it into an outpatient procedure.   (11 ref)

159.    Ireson, C. L., & Grier, M. R. (1998). Evaluation of variances in patient outcomes. Outcomes Management for Nursing Practice, 2(4), 162-6.
Abstract: New knowledge and understanding about improving the quality and reducing the costs of care will come from careful scrutiny of the variations in the outcomes of nursing interventions. Nurses need to systematically identify and measure outcomes, understanding the probabilistic nature of these patient responses to the care received. Using a formative evaluation process, nurses should measure degrees of patient outcomes over time to ascertain the effects of nursing care and analyze the variances in these observed outcomes from what was expected. Critical pathways are valuable tools for guiding evaluations of nursing care along a timeline and can lead to improvements in nursing care. [References: 20]

160.    Roblee, R. D. (1998). Interdisciplinary dentofacial therapy (IDT): a comprehensive team approach. Ann R Australas Coll Dent Surg, 14, 41-7.
Abstract: Modern dentistry, with its various disciplines, has an exciting and unmatched potential to enhance the overall quality of life for our patients. In this environment one of the greatest challenges for clinicians is to properly utilize this vast potential. It can be very difficult to consistently establish health and physiological occlusal relationships in patients with significant dental, periodontal, dentoalveolar, temporomandibular, and/or skeletal problems. This task is further complicated by ever-increasing patient and provider demands for results with optimal dentofacial aesthetics and long-term stability. Interdisciplinary Dentofacial Therapy (IDT) is a proven diagnostic and clinical pathway for consistently maximizing patient outcomes in these complicated areas. Within a climate of increasing scientific and technological advances in dentistry, today's dental professional must study continuously to stay abreast in one area, let alone in all of them. The responsibility to the patient, however, is to utilize fully the extensive options that the profession can provide. As stated above, a proven treatment philosophy for accomplishing this is called Interdisciplinary Dentofacial Therapy, or IDT. When properly performed, IDT can produce unparalleled professional satisfaction and camaraderie by reaching higher levels of patient care through optimal coordination of knowledge and skills in the various disciplines. In addition, IDT can consistently produce optimal treatment results while simultaneously producing profound practice management, time management and marketing benefits for practitioners. This paper briefly describes these benefits while defining the philosophies and hallmarks of IDT. It will also give insight into the implementation of IDT and why it will be even more necessary and valuable in the future than it is today.

161.    Leyden, C. G., & Abbott, C. (1998). Traumatic brain injury care path. Pediatric Nursing, 24(5), 470-3.

162.    Leininger, S. (1998). Quality circle of joint care. Orthopaedic Nursing, 17(5), 74-83.
Abstract: The implementation of clinical pathways in home care, along with the use of outcome tools and the development of benchmark physical therapy guidelines, is discussed in this article. Three tools were developed by an interdisciplinary team led by an orthopaedic surgeon and the clinical nurse specialist (CNS) in cooperation with several members of the home care staff.

163.    Korcz, I. R., & Moreland, S. (1998). Telephone prescreening enhancing a model for proactive healthcare practice. Cancer Practice, 6(5), 270-5.
Abstract: PURPOSE: This article explicates the process of developing and implementing a contemporary, innovative program using the telephone as a tool for prescreening newly diagnosed cancer patients before their arrival at the cancer center. As another element of existing models of psychosocial care, this service lays the foundation for the efficient delivery of clinical social work services. DESCRIPTION OF PROGRAM: In the Surgical Oncology Clinic of the M.D. Anderson Cancer Center in Houston, Tex, 28 patients were contacted as part of a telephone prescreening model of a practice program from February 1, 1995 through March 31, 1995. Using a structured telephone interview format, two clinic social workers contacted patients and provided information on social work services. Patients needing resource assistance were provided with community referrals. Using the information from the telephone call, a brief outpatient assessment was completed for each patient before his or her arrival at the clinic. During the initial clinic visit, each new patient was met by the social worker to conduct a qualitative interview and address specific treatment-related concerns. OUTCOME OF PROGRAM: The patients expressed their appreciation of the interest of the social work staff and their satisfaction with the information provided. In addition, obtaining patient information and identifying patient needs before the initial visit allowed social workers to use clinic time more efficiently. Because of restructuring, the Surgical Oncology Clinic was eliminated and use of the intervention suspended. Based on the encouraging results of the telephone prescreening model of care program, reinstating the program in the future would include expanding its hours of operation to reach individuals who are not at home during the hours of 8:00 am 25:00 pm and including language assistance to address the needs of the increasingly multicultural population. CLINICAL IMPLICATIONS: Telephone prescreening is one strategy for personalizing psychosocial assessment. In this era of outpatient day surgery and cost-controlled managed healthcare, the benefits of prescreening are empowerment for both patients and multidisciplinary team members. The future holds promise for telephone prescreening to become part of the collaborative clinical pathways model of the disease-site centers concept.

164.    Lowe, C. (1998). Care pathways: have they a place in 'the new National Health Service'? Journal of Nursing Management, 6(5), 303-6.
Abstract: AIM: To discuss the use of Integrated Care Pathways (ICPs) as tools for ensuring cost-effectiveness and high quality patient-focused care. To examine how electronic pathways combining process, practice and audit might be effectively used by Primary Care Groups as a tool to integrate care within the 'New National Health Service'. KEY ISSUES: It has been argued that for doctors pathways lead to 'cook book medicine' and for nurses they move practice away from patient-centred care back to a disease/task-based model. This article explores the origins of pathways, addresses the concerns of critics and goes on to describe a pathway strategy. CONCLUSIONS: Pathway development offers the potential to create a coherent plan of care and treatment (across primary/secondary care) which incorporates evidence-based practice and reduces fragmentation and duplication whilst aiding co-ordination and communication. The incorporation of clinical indicators and measurable goals ensures the audit process is embedded. [References: 7]

165.    Miracle, P., Savage, T., Hickey, T., Mountjoy, B., & Martin, P. A. (1998). Designing a system for ambulatory obstetric case management. Lippincott's Case Management, 3(4), 160-7.
Abstract: The authors describe the development of critical pathways for ambulatory obstetric case management. When case management was identified as needed, but published work in outpatient obstetrics could not be found, four nurses used this opportunity to design a cost-effective system leading to quality outcomes. The driving force was the need for a format that directed comprehensive consistent care delivered by a large multidisciplinary health care team. Design issues included capturing leading edge standards of care and user friendly formats for all caregivers. Throughout a period of 2 years, a trifold format was developed for all obstetric patients, and 15 bifold formats were developed for patients with specific high-risk diagnoses. The format design facilitated cost-effective quality care and is expected to improve patient outcomes. A research study has been initiated to measure effectiveness of the design.

166.    Ley, A. (1998). Fast tracking in cardiac surgery: the St. Francis experience. Lippincott's Case Management, 3(4), 155-9.

167.   Kathol, D. D., Geiger, M. L., & Hartig, J. L. (1998). Clinical correlation map. A tool for linking theory and practice. Nurse Educator, 23(4), 31-4.
Abstract: To facilitate application of theoretical knowledge to clinical practice, students develop a clinical correlation map that diagrams the relationships between each client's assessment and diagnostic data, medical treatment, human responses, and nursing diagnoses. In addition to the tool's benefits to the student, faculty can quickly assess the student's understanding of pathophysiology, diagnostic testing, treatment, nursing diagnoses, and interventions.

168.    Claeys, M., Mosher, C., & Reesman, D. (1998). The POP Program: the patient education advantage. Orthopaedic Nursing, 17(4), 37-47.
Abstract: In 1992, a preoperative education program was developed for total joint replacement patients in a small community hospital. The goals of the program were to increase educational opportunities for the joint replacement patients, prepare patients for hospitalization, plan for discharge needs, and increase efficiency of the orthopaedic program. Since 1992, approximately 600 patients have attended the education program. Outcomes have included positive responses from patients regarding their preparedness for surgery, increased participation in their plan of care, coordinated discharge planning, decreased length of stay, and progression across the continuum of care. A multidisciplinary approach to preparing patients for surgery allows for a comprehensive and efficient education program. Marketing of successful programs can enhance an institution's competitive advantage and help ensure the hospital's viability in the current health care arena.

169.    Partrick, D. A., Bensard, D. D., Moore, E. E., Terry, S. J., & Karrer, F. M. (1998). Ultrasound is an effective triage tool to evaluate blunt abdominal trauma in the pediatric population [see comments]. Journal of Trauma-Injury Infection & Critical Care, 45(1), 57-63.
Notes: Comments: Comment in: J Trauma 1999 Feb;46(2):357-9, Comment in: J Trauma 1999 Dec;47(6):1162-3
Abstract: BACKGROUND: Although computed tomography has been considered the diagnostic modality of choice for pediatric patients with blunt abdominal trauma (BAT), it is costly, time-consuming, requires sedation, and may be associated with complications in young children. Abdominal ultrasonography (US) is a promising modality in the evaluation of BAT that is quick, noninvasive, repeatable, and cost-effective. We hypothesized that emergency department US, performed by trauma surgeons, is a useful triage tool for pediatric BAT that reduces the need for computed tomography. METHODS: The 230 children (<18 years old) with suspected BAT were initially evaluated with US in the emergency department by surgeons. Subsequent computed tomographic scan or exploratory laparotomy was performed as indicated by the key clinical pathway. RESULTS: Twelve children (5.2%) had documented intra-abdominal injuries. All five injured children with significant intraperitoneal fluid were identified by US. Of the seven patients who had intra-abdominal injury not detected by US, six sustained solid organ injuries that were managed nonoperatively. Extrapolated reductions in hospital charges due to the decreased number of computed tomographic scans total $130,000. CONCLUSIONS: Using US as a triage tool may dramatically reduce the cost of pediatric BAT evaluation while being able to quickly identify significant intraperitoneal fluid that requires further evaluation and possible laparotomy.

170.    Stearley, H. (1998). All aboard--riding on the fast track. Revolution, 8(2), 24-8.

171.    White, A. W., & Wager, K. A. (1998). The outcomes movement and the role of health information managers. Topics in Health Information Management, 18(4), 1-12.
Abstract: The resounding demand that health care organizations demonstrate their effectiveness in providing quality patient services is being voiced by federal and state governments, managed care organizations, the Joint Commission on Accreditation of Healthcare Organizations, and businesses and insurers purchasing and paying for health care services. The outcomes movement arose in response to these demands and is intended to provide a means for increasing medical effectiveness and reducing costs. The article presents an overview of the outcomes movement and discusses the use of outcomes data, the challenges and issues associated with outcomes assessment, and how health information managers can play a role in facilitating outcomes assessment. It suggests areas of professional development that health information managers may wish to explore. Copyright (c) 1999 by Aspen Publishers, Inc.   (25 ref)

172.    Goldberg, R., Chan, L., Haley, P., Harmata-Booth, J., & Bass, G. (1998). Critical pathway for the emergency department management of acute asthma: effect on resource utilization. Annals of Emergency Medicine, 31(5), 562-7.

173.    Ling, P. H. (1998). Managing care through collaboration -- the NCH experience... New Changi Hospital. Singapore Nursing Journal, 25(2), 21-3.
Abstract: Integrated care or collaborated management of patients is a concept which may seem unattainable in the past. However, with the current demographic trend in Singapore and a growing awareness of cost-containment, maximal manpower and resource utilisation, it is a practice that nursing, medical and paramedical staff will have to embrace in years to come. In line with New Changi Hospital's mission statement, the idea of collaborative care is developed and maintained through the implementation and evaluation of clinical pathways--a structured tool in managing patients' care in the hospital. Among its numerous benefits is its direct link to Continuous Quality Improvement (CQI), a concept very much believed by many other health care organisations in Singapore.   (5 ref)

174.    Lambert, M. C. (1998). Delivering adequacy in PD therapy. Edtna-Erca Journal, 24(2), 33-9.
Abstract: Providing appropriate peritoneal dialysis is an ongoing challenge to renal care providers. As the residual renal function and the peritoneal permeability are likely to change with time, the dose provided by the PD regimen needs to be adjusted. Rather than waiting for clinical signs of underdialysis, the practising nephrologist and the PD nurse today have access to diagnostic tools to assist in the prescription of adequate therapy. Peritoneal dialysis prescription involves setting up a personalized dialysis schedule aimed at obtaining satisfactory clearance and ultrafiltration rates while respecting the patient's life-style as far as possible. The PD nurse has the most patient contact and thus plays a pivotal role with the other healthcare professionals in the care of the patients. As providers, it is our responsibility to inform the patients about their own care. As PD is a method of home dialysis, patients must have self responsiveness, technical and psycho social skills to deal well with the method. [References: 9]

175.    Tucci, R. A., & Bartels, K. L. (1998). Ovarian cancer surgery: a clinical pathway. Clinical Journal of Oncology Nursing, 2(2), 65-6.
Abstract: Clinical pathways are useful tools in providing quality care while decreasing the cost of that care. Pathways help to facilitate managed care, identify patient and family educational needs, encourage multidisciplinary communication, and expedite patient discharge. This article discusses a clinical pathway for ovarian cancer surgery.

176.    Roberts, J. (1998). The effects of technology on triage in A & E. Accident & Emergency Nursing, 6(2), 87-91.
Abstract: Within the specialty of Accident and Emergency (A & E) nursing, triage is a term meaning to classify or sort patients according to their need for care (Blythin 1988). Burgess (1992) views this process as a means of prioritizing patients in order, so that the more seriously ill or injured are seen first (Table 1). Triage performance is measured in the author's department by computer. This technological source is used to record the patient's arrival time and the time at which the patient is triaged. Technology is defined by the Oxford Dictionary (1996) as 'the study of mechanical arts and science, their application in industry'. This paper explores the impact of this technology and the related issues on the A & E triage nurse, and will focus on issues related to the Patients' Charter (1991), resource implications, safety and staff training. In conclusion, the quality of a patient's total care, in which the author participated, is discussed with reference to the related issues and implications for future practice. [References: 23]

177.    Schwoebel, A. (1998). Care mapping: a common sense approach. Indian Journal of Pediatrics, 65(2), 257-64.
Abstract: Because of trends in the health care environment, hospitals are searching for ways to continuously improve the quality of care and to decrease the costs of care. One approach that is gaining widespread recognition throughout the United States is the use of case management and practice guidelines such as critical paths, CareMaps, and in the neonatal field, NeoMaps. The NeoMap is a clinical tool which delineates practice guidelines for each discipline that provide care to a specific infant population. It reduces variation in clinical process and thereby has been shown to improve the quality of infant care. When practice guidelines are linked to both health and economic outcomes, they have significant impact on health care costs. In this paper, case management and the development of the NeoMap will be described in relation to the Intensive Care Nursery (ICN) at Pennsylvania Hospital.

178.    Cheah, T. S. (1998). Clinical pathways--the new paradigm in healthcare?  Med J Malaysia, 53(1), 87-96.
Abstract: A clinical pathway defines the optimal care process, sequencing and timing of interventions by doctors, nurses and other healthcare professionals for a particular diagnosis or procedure. It is a relatively new clinical process improvement tool that has been gaining popularity across hospitals in the USA, Australia and United Kingdom. Clinical pathways are developed through collaborative efforts of clinicians, nurses, pharmacists, physiotherapists and other allied healthcare professionals with the aim towards improving the quality of patient care. Clinical pathways have been shown to reduce unnecessary variation in patient care, reduce delays in discharge through more efficient discharge planning, and improve the cost-effectiveness of clinical services. The approach and objectives of clinical pathways are consistent with those of total quality management (TQM) and continuous quality improvement (CQI) and is essentially the application of these principles to the patient's bedside. This article examines the proliferation in the use of clinical pathways, its benefits to the healthcare organisation, its application as a tool for CQI activities in direct relation to patient care and the medico-legal implications involved.

179.    Fielden, N. M. (1998). Community-acquired pneumonia. Perspectives in Respiratory Nursing, 9(1), 1-2, 4, 6 passim.

180.    Ahmad, E. A., & Keng, M. T. M. (1998). Variance management system: achieving quality through data management. Singapore Nursing Journal, 25(1), 24-6.
Abstract: In the last ten years, healthcare in Singapore has undergone many changes, among which are escalating healthcare costs, highly revolutionised surgical and medical procedures and restructuring of hospitals. Healthcare delivery has also improved, such as the move from task-oriented nursing to more individualised patient care and from disintegrated care delivery to a more collaborative multi-disciplinary approach. The use of Clinical Pathways or Critical Pathways is a step forward in providing high quality patient care within the constraints of limited healthcare resources. Variance Management System is an imperative tool in Clinical Pathway implementation that links Continuous Quality Improvement and Clinical Audit with clinical practice.   (3 ref)

181.    Petchell, A., Keenan, A., & Landorf, K. (1998). National clinical guidelines for podiatric foot orthoses. Australasian Journal of Podiatric Medicine, 32(3), 97-103.

182.    Hirsch, J., Donaldson, N. E., Rutledge, D. R., Pravikoff, D., Levy, J., Paxton, J. A., Yee, M. A., & Wolf-Wilets, V. (1998). Nursing leadership and systems... 31st Annual Communicating Nursing Research Conference/12th Annual WIN Assembly, "Quality Research for Quality Practice", held May 7-9, 1998 in Phoenix, Arizona. Communicating Nursing Research,  31:193-6.

183.    Stempel, D. A., Brunton, S., Clanton, M., Mackowiak, J., Alam, R., & Rossoff, L. J. (1997). Issues in diagnosis and therapy. American Journal of Managed Care, 3(Suppl), S29-42, S47-48.
Abstract: The management of rhinitis begins with a careful history and review of symptoms, a thorough physical examination with laboratory and allergy tests as appropriate, an accurate diagnosis, and attention to any comorbidities that may be present and require treatment. Typically, treatment begins with a trial of over-the-counter medications, which may be recommended by the physician, or-as is often the case in the "real world"-are initiated by patients themselves. In this portion of the symposium, the panelists reviewed symptoms, clinical findings from the history and physical examination, the impact of comorbid conditions, quality-of-life issues, patient satisfaction, and the safety, efficacy, and indications for various treatment options. They focused on the need for treatment guidelines, and the goals of treatment algorithms. In particular, they reviewed and evaluated a treatment algorithm already in use at a healthcare plan in Washington State. The ideal algorithm, they agreed, would be one that provided "boundary guidelines" to direct physicians while still preserving the physician's freedom to exercise clinical judgment.   (18 ref)

184.    Jones-Baucke, D. L. (1997). A qualitative study of the implementation of a system to increase nurses' use of standardized nursing languages. Unpublished doctoral dissertation, UNIVERSITY OF WASHINGTON , Seattle, WA.
Abstract: If healthcare professionals are to measure the effect of their services on the clients they serve, they must capture data describing their services with a standardized language. Past studies have indicated that nurses' use of SNLs is sporadic and varies across organizations and geographic boundaries. This study successfully utilized technology to improve nurses' and healthcare administrators' attitudes towards using standardized nursing languages (SNLs), for a variety of patient care and administrative functions. The specific aims of the study were to better understand barriers to SNLs use, to generate specifications for a system to improve nurses' use of SNLs, to develop and test this system, to assess the robustness of the SNLs for describing practice during the testing of the system, to assess whether the nurses trialing the system actually developed a schema of the SNLs being utilized, and to explore the utility of the data generated from this system for use in a variety of clinical and administrative functions. The methodology used in this study was participatory action research. However, both qualitative and quantitative data were collected and analyzed. The conceptual framework used to guide the intervention involved sociotechnical design theory, organizational theory, human computer interaction theory, schema theory, and decision making theory. The intervention utilized employed both a technological and educational approach. Specifically, the NANDA (North American Nursing Diagnoses Association) and the NTC (Nursing Intervention Classification) nomenclatures were bar coded and a front end software was developed and tested by nurses on a neurosurgical and medical hospital ward. Findings include nurses' reports that the SNLs utilized described their practice 85% of the time, the system improved nurses' attitudes and beliefs toward using SNLs and the majority of the administrators thought that the data from the system had high utility for improving patient outcomes, developing care plans and critical pathways, costing of nursing services, measuring acuity and benchmarking. The system also demonstrated a large range of nursing diagnoses across medical DRGs, indicating the inadequacy of using medical classification systems for analyzing the efficiency and effectiveness of nursing care.

185.    Bertram, D. A., Thompson, M. C., Giordano, D., Perla, J., & Rosenthal, T. C. (1996). Implementation of an inpatient case management program in rural hospitals. Journal of Rural Health, 12(1), 54-66.
Abstract: The objective of the study was to identify factors that affected the implementation of an inpatient case management program in rural hospitals. The hospitals studied were from the Western New York Rural Health Care Cooperative. Five of the hospitals implemented the program in 1992. A qualitative evaluation was conducted by analyzing tape-recorded interviews with nurses and chief executive officers to identify obstacles to and facilitators of program implementation. Many obstacles to implementation could be traced to workload and time constraints, physician autonomy concerns, and limited nursing staff and physician participation. Implementation was facilitated foremost by the effort and supportive attitudes of nursing leaders and hospital chief executive officers. This study concluded that it should be possible to successfully implement conceptually sound managed care and case management programs in rural hospitals, but it will require a relatively long period of support, especially from hospital administration and nursing leaders.   (42 ref)

186.    Raymond, D. P. (1996). Nurse-client relationship and process of recovery in schizophrenic inpatients. Unpublished doctoral dissertation, UNIVERSITY OF ALABAMA AT BIRMINGHAM, Birmingham, AL.
Abstract: Schizophrenia is a chronic psychiatric disorder of social significance requiring a high degree of community resources and health care expenditures. Recovery from an acute psychotic episode is a critical period in the treatment of schizophrenia. Nursing interventions that effectively support clients during this recovery period are crucial. The purpose of this study was to explore and describe the nurse-client relationship and the process of recovery in schizophrenic inpatients. Four research questions were addressed. Two questions related to the phases of the nurse-client relationship and to the sequences of action/interaction in the recovery process. The remaining two questions focused on clients' perspectives on effectiveness of nursing interventions and self-regulatory mechanisms. Qualitative data were collected from the hospital charts of 16 schizophrenic inpatients experiencing psychosis. The study included nine individuals diagnosed with schizophrenia. Seven were diagnosed with schizoaffective disorder. The entire hospital stay of the 16 participants from admission to discharge was tracked. Twelve of the 16 participants were interviewed. The interview questions focused on admission, course of hospitalization, and discharge. Clients were asked to identify helpful, self-help, and unhelpful interventions. Peplau's nurse-client relationship phases served as organizing categories for the data. The chart data and interview data were analyzed using content analysis. Themes which emerged in the early phases included hope/hopelessness, fear, power/control, anger, self-esteem/self-worth, and loneliness. Two themes, coping and denial, emerged in the later phases reflecting two distinct subgroups. Nursing interventions in the early phases focused on meeting lower level needs, while those in the later phase focused on higher level needs. The interview data revealed that clients identified numerous helpful staff and self-help interventions and fewer unhelpful interventions. Findings suggest that treatment which is both standardized, yet individualized, may produce the best outcomes. Further, the study design suggest a mechanism for the development of critical pathways for the care of psychiatric clients.

187.    Miller, J., Sater, K., & Mazur, L. (1996). Impact of clinical pathway in the care of febrile infants... including commentary by Stephenson T. Ambulatory Child Health, 2(2), 123-7.
Abstract: Objective: To assess the efficiency of care of a clinical pathway for febrile infants. Design: Before and after implementation of a clinical pathway. Setting: Hermann Children's Hospital in Houston, Texas. Patients: Infants less than 28 days of age with a rectal temperature greater than 38 degrees C. Main outcome measures: Time to admission to the pediatric unit from the emergency center, length of hospital stay, and total hospital costs. Results: Comparison of 42 pre-pathway and 34 post-pathway patients showed a significant decrease in total hospital costs, $3176 vs. $2255, and a trend towards decreased time to admission to the pediatric unit from the emergency center, 4.9 vs. 3.9 hours. Conclusions/implications for practice: The implementation of a clinical pathway for infants with suspected sepsis resulted in significant savings. The time from presentation to the emergency center and admission to the pediatric unit was also significantly shortened.   (12 ref)

188.    Hampton, D. C. (1996). The effect of nursing coordinated care delivery on patient empowerment and selected clinical outcomes. Unpublished doctoral dissertation, UNIVERSITY OF CINCINNATI ** 1996 PH.D.
Abstract: The purposes of this study were to: (a) assess the effect of care coordination on patient empowerment, (b) determine the relationship between the patient's level of empowerment prior to surgery and the accomplishment of discharge recovery outcomes, (c) determine if empowerment and specific physiological variables were significant predictors of length of stay (LOS) after surgery, and (d) describe selected clinical recovery outcomes that may have been influenced by care coordination. The theoretical/conceptual framework for this study was based on empowerment models and assumptions, extant nursing coordinated care delivery models, outcomes research related to coordinated care, and recent research related to individual empowerment. The researcher hypothesized that coordination of care, through the implementation of a unit-based structure and through the use of CareMaps(tm), would facilitate the development of empowerment and the achievement of recovery goals of coronary artery bypass graft (CABG) patients. A descriptive-comparative pretest-posttest design was used in this study. The 120 CABG patients that were included in the study were designated into one of two groups (n = 60 patients per group) for the data analysis process, depending upon whether their care was coordinated through the use of a regular recovery or rapid recovery CareMap(tm). The empowerment level of patients in both groups was measured prior to surgery and at discharge through the use of a 16-item instrument. Results of the study revealed that coordination of care can influence recovery outcomes for CABG patients. Patients in the rapid recovery group had a significantly shorter ventilator time, critical care unit LOS, and postoperative LOS than did regular recovery patients. Empowerment level was not found to be correlated with LOS or accomplishment of CareMap(tm) recovery outcomes. Predictors of LOS included complications after surgery, time on the ventilator after surgery, gender, and number of bypass grafts. The empowerment level of patients did not change significantly from prior to surgery to the time of discharge, but patients in the rapid recovery group had a significantly overall higher empowerment level than did regular recovery patients. The empowerment instrument used in this study was found to have good overall reliability and construct validity.

189.    Portus, R. (1995). Process control: clinical path analysis. In  Informatics: the infrastructure for quality assessment & improvement in nursing. Proceedings of the Fifth International Nursing Informatics Symposium Post-Conference: Austin, Texas, June 24-25, 1994 (pp. 68-76). San Francisco, CA: UCSF Nursing Press.

190.    Canfield, G., Compogiannis, L., Donoghue, D., Leyden, P., McEvoy-Dodson, K. A., & Sparr-Perkins, R. ( 2000 May). Analyzing the cost of spinal fusion. Surgical Services Management, 6(5), 36, 39-41.