Care Maps, Clinical Paths/Pathways, Critical Paths/Pathways 1986-1994 and undated items/Oct 99

     1.    Weaver, F. M., Hynes, D. M., Guihan, M., Byck, G., Wang, S., Conrad, K., & Demakis, J. G. ([s.d.]). Prevalence of subacute care patients in Department of Veterans Affairs Hospitals [abstract]. Abstract Book/Association for Health Services Research, 14, 318-319.
Abstract: RESEARCH OBJECTIVE: Subacute care can be defined as a transitional level of care for medically stable patients who no longer require daily physician care but who require more care than can typically be provided in a skilled care facility. One objective of this Congressionally mandated study was to determine the prevalence of VA patients at the subacute level being cared for in acute care beds. STUDY DESIGN: Subacute care criteria developed by InterQual, Inc. were retrospectively applied to an existing sample of medical and surgical admissions used for quality assurance utilization reviews between October 1, 1993 and March 31, 1994 at a stratified random sample of 43 VAMCs. A total of 858 admissions were reviewed. additional data including patient demographics, diagnosis, and discharge status were abstracted from the VA's Patient Treatment File. PRINCIPAL FINDINGS: Over one-third of all cases reviewed (38%) contained at least one subacute day. Medical cases were more likely to contain subacute days than surgical cases (42% v. 33%). The average length of stay for patients with any subacute days was 12.67 (s.d.=12.4); of which 6.78 days or 54% were subacute. Patients with admissions containing subacute days had significantly longer hospital lengths of stay, were older, and were more likely to either die or be discharged to a community nursing home than patients with admissions that did not have any subacute days. Diagnoses that most frequently resulted in subacute days included chronic obstructive pulmonary disease, pneumonia, major joint replacement, and cellulitis. CONCLUSIONS: These data suggest that there may be specific patient disease subgroups that may benefit from placement in subacute settings. A prospective study of subacute care in VA hospitals is needed to determine how to identify patients who are most likely to have subacute needs so that they can be cared for in the most appropriate setting. Development or modification of clinical pathways to incorporate subacute care for specific groups (e.g., diagnosis groups) who are most likely to require subacute care would be a good place to start. RELEVANCE TO CLINICAL PRACTICE AND POLICY: The VA should consider the feasibility and cost-effectiveness of strategies to meet the subacute care needs of these patients either in lower intensity/cost VA beds or by placement in a community subacute level facility.  (Abstract by: Author)

     2.    Soumerai, S. B., McLaughlin, T. J., Gurwitz, J., Guadagnoli, E., & Hauptman, P. ([s.d.]). A randomized trial of opinion leader education plus performance feedback to improve quality of care for acute MI [abstract]. Abstract Book/Association for Health Services Research, 14, 101-102.
Abstract: RESEARCH OBJECTIVE(S): To determine the effectiveness of guideline implementation combining education of clinicians by local medical opinion leaders (MOLs) and hospital-level feedback on use of: 1) life-saving drugs for acute MI (thrombolytics and aspirin in eligible elderly, Beta-blockers in all eligible patients); and 2) a potentially harmful therapy (prophylactic lidocaine). STUDY DESIGN: We conducted a randomized controlled trial with hospital as the unit of analysis. Study subjects included all patients with acute MI who were admitted to study hospitals over one year pre- (1992-1993) or post-intervention (1995-1996). We reviewed medical records of 2409 pre- and 2930 post-intervention patients at 20 MOL and 17 control hospitals in Minnesota. Using a previously-validated survey, we identified MOLs at each intervention hospital. MOLs used several techniques to improve practice, including lectures, small groups, informal consultations, and revisions of protocols and clinical pathways. Education and feedback focused on: 1) national consensus guidelines and evidence regarding use of specific drugs; 2) comparative prescribing performance; and 3) barriers to best practices. At control hospitals, quality assurance staff received minimal feedback regarding prescribing practices. We measured changes from pre- to post-intervention in the proportion of eligible patients at each hospital receiving thrombolytic agents, Beta-blockers or aspirin (without contraindications); and the proportion of patients receiving lidocaine without indications. PRINCIPAL FINDINGS: Demographics, severity, and comorbidity were similar at MOL and control hospitals. Among MOL hospitals, the average rate of use of IV Beta-blockers rose from 0.55 at baseline to 0.80 at follow-up (+45%) compared with 0.58 to 0.71 (+22%) at control hospitals (p=0.05). For IV or oral Beta-blocker use, the respective changes were +28% and +10% (p=0.04). Aspirin use rose 28% and 10%, respectively (p=0.13). Lidocaine use declined by over 50% in both groups to about 0.11 (p=0.93). The intervention did not increase thrombolytic use. CONCLUSIONS/RELEVANCE TO CLINICAL PRACTICE AND POLICY: MOL education and feedback may be effective in increasing use of some beneficial therapies for acute MI (e.g., Beta-blockers and aspirin). However, they may not be effective when strong secular trends exist (e.g., decreased use of lidocaine), or when major barriers to change are present (e.g., thrombolytics in the elderly).  (Abstract by: Author)

     3.    Simpson, K. S., Andersson, F., Shakespeare, A., Oleksy, I., & Hatziandreu, E. J. ([s.d.]). A conceptual framework for trans-national modeling of cost effectiveness: an example from AIDS treatment in Europe [abstract]. Abstracts / Annual Meeting, International Society of Technology Assessment in Health Care, 9, 68.
Abstract: This paper presents a conceptual framework for the construction of cost effectiveness models that will maximize use of efficacy data available early in a technology's life cycle, while simultaneously maximizing the acceptability of the results in different countries.  An example from AIDS treatment in European countries is used to illustrate important concepts.  The chronically strained health care budgets in developed nations makes cost effectiveness analysis (CEA) increasingly important for informing health care policy decisions related to new technology. The greatest potential contribution of CEA is early in a technology's adoption cycle when few country-specific data are available.  At this stage the most feasible study design is based on a modeling approach. The model should be designed so that it translates the artificial clinical path and resource flow patterns common to the clinical trials on which the efficacy data are based, into a realistic, transparent, and unbiased analysis that bears a reasonable resemblance to natural practice patterns.  A model that will be used to assess CEA of a new technology in more than one country poses special design problems. Before beginning the model formulation, the analyst should assess all the major factors that could influence the effectiveness of a technology in a population, and the factors that might affect the costs of the technology.  The types of alternative treatments available in each country must be summarized, and country-specific policy issues must be identified.  This paper describes the process used to isolate and summarize the relevant factors.  The result of using this process is illustrated with examples from a project to design a CEA model to assess the value of a new antiviral drug for AIDS patients in Switzerland, France, Italy, Germany, and the United Kingdom.  Variables discussed are relevant for CEA related to infectious diseases.  Specifically we will discuss how to accommodate country-specific variations in: trial entry criteria; opportunistic disease epidemiology; routine treatment standards; patient compliance; bed capacity; medical practice patterns; survival rates; price structure; and health policy (political) constraints.  (Abstract by: Author)

     4.    Simpson, K. N. ([s.d.]). Design and measurement issues in economic studies of costly chronic illnesses: examples from HIV-drug therapy [abstract]. Annual Meeting of International Society of Technology Assessment in Health Care, 11, Abstract no. 83.
Abstract: Pharmacoeconomic methodology is rapidly evolving and can produce valid knowledge about the comparative efficiency of competing drug treatments. It may therefore increasingly be used to inform decisions about what to include on drug formularies and thus influence rationing decisions. If pharmacoeconomic data will be used to exclude drugs from formularies then it is especially important that studies be valid. Pharmacoeconomic studies of chronic, high cost diseases may be especially vulnerable to influences from design choices. These types of studies may on the surface seem straight forward to perform. However, for some types of costly chronic illnesses, economic analysis methods must be carefully selected to minimize distortion from "penalty for survival," high baseline costs and poor baseline health status. This paper will use examples from HIV therapy to illustrate the design issues that must be considered for economic analysis of drugs for costly chronic diseases. The analyst's task is to translate the artificial clinical path and resource flow patterns seen in a clinical trial environment into a realistic, transparent, and unbiased analysis that bears a reasonable resemblance to the patterns seen in natural practice situations. The fidelity of such a "translation" is influenced by assumptions made about prophylactic, treatment and palliation regimens for both acute and chronic manifestations of a chronic disease. Four design influences must be recognized: 1) the choice of the type of analysis (cost -comparison, -effectiveness, -utility or -benefit); 2) the choice of health-related quality of life (HRQOL) or utility data collection methods (indices, standard gamble, time tradeoff, rating scale); 3) the length of time included in the analysis; and 4) assumptions made about current prophylactic and acute therapy interactions. This paper illustrates through decision modeling of costs and outcomes how assumptions about current practice and design issues may change cost effectiveness ratios. Examples from a preliminary analysis indicate that assumptions about the use of drugs, such as ziduvodine, zalciatabine, pentamidine, dapsone, mepron, trimethoprim sulfa or rifabutin can cause variations in marginal cost effectiveness ratios from $20,000 to $60,000 (US) per life year (LY). Survival assumptions and utility measurement decisions may affect cost utility ratios by between $10,000 and $80,000 per QALY. Recommendations for designs that minimize these influence will be presented.  (Abstract by: Author)

     5.    Seid, M., Quinn, K., Richardson, P. J., & Kurtin, P. S. ([s.d.]). Outcomes for hospitalist pediatricians: comparison to community pediatricians for asthma and bronchiolitis [abstract]. Abstract Book/Association for Health Services Research, 14, 14-15.
Abstract: RESEARCH OBJECTIVE(S): The "hospitalist" is a recent phenomenon in managed care organizations. This salaried internist/specialist, designated to care for patients admitted to the organization's hospital, becomes the attending physician during a patient's hospital stay. In theory, a hospitalist should be more efficient due to familiarity with caring for acutely ill patients and with hospital processes, and availability on site (Moore, 1997; Wachter & Goldman, 1996). Research designed to test this hypothesis, however, is sparse (La Puma, 1996). While support exists for a positive relationship between experience and outcomes for specific procedures (Moore & Bennett, 1995) and conditions (see Wachter & Goldman, 1996), and anecdotal evidence abounds (e.g. Moore, 1997), there have been no published studies testing this hypothesis. MOreover, no data exist to examine whether this hypothesis holds true in a pediatric tertiary care setting. The objective of the current study was to compare inpatient costs and clinical outcomes between hospital-based and community pediatricians for children admitted to hospital with asthma or bronchiolitis. After adjusting for severity of illness, hospitalist pediatricians were hypothesized to have lower average costs per case and length of stay, more patients discharged on time, and no differences in clinical outcomes when compared to commuity pediatricians. STUDY DESIGN: The study was a retrospective design examining all patients admitted to a Southern California children's hospital with APR-DRG 96 (Asthma and Bronchiolitis) between July 1, 1995 and June 30, 1996. Costs were measured via average direct costs per patient, average length of stay, and percent of patients discharged before 11 am. Clinical outcomes were measured via proportion of patients with an ED visit within 30, 60, and 90 days, percent of clinical pathway compliance, and number of quality assurance incidents per 100 patients all comparisons were adjusted for severity of illness suing the APR-DRG Severity of Illness grouper. PRINCIPAL FINDINGS: The hospitalist pediatricians cared for 462 inpatients, while the community pediatricians cared for 260. Chi-squared analysis indicated no significant difference between the two groups in severity of illness score. Independent-sample T-tests indicated no significant difference in average length of stay. There were no differences between the groups in patient PICU days, and although the hospitalists were the attending M.D. for a greater proportion of patients admitted via the ED, there was no difference in cost between ED-admitted and non-ED-admitted patients. As there was no difference in severity of illness between physician groups, this variable was not used as a covariate. Independent-sample T-tests showed no significant differences bewteen the two groups in average direct costs, and the raw difference tended to favor community pediatricians. There were no differences in the proportion of patients seen in the ED after discharge within 3, 60, and 90 days, no were there differences in on-time discharges or quality assurance incidents. CONCLUSIONS: The absence of significant differences in cost or clinical outcomes between the two physician groups fails to support the hypothesis that a hospitalist pediatrician is able to provide more efficient, higher quality care than a community pediatrician for patients admitted with asthma and bronchiolitis. RELEVANCE TO CLINICAL PRACTICE AND POLICY: Given increasing pressures to cut inpatient costs and increasing numbers of hospitalists nationwide research examining the cost-effectiveness and clincal outcomes of hospitalist pediatricians relative to their community counterparts is timely and important. Such research is useful to managed care decisionmakers contemplating implementation of a hospitalist position as well as to organizations with pediatric hospitalists in place. Research such as this would also be important to policy makers and researchers concerned with health delivery structure and financing and its effect on quality of care for children.  (Abstract by: Author)

     6.    Rosen, L., Sandhu, R., Reed, J., Marchetto, K., & Frailey, W. ([s.d.]). Readmissions following surgery as performance indicators [abstract]. Abstract Book/Association for Health Services Research, 15, 207.
Abstract: RESEARCH OBJECTIVE: Readmission rates, planned or unplanned, are useful for hospital resource consumption, but unplanned readmissions can be used to develop performance indicators to prevent premature discharge and determine overall outcome within a high volume Department of Surgery. STUDY DESIGN: From 7/1/96 to 6/1/97, 3,877 patients underwent major surgery within 8 surgical specialties. The surgeries were selected using those 15 principal procedure codes with the highest volume. The overall readmission rate within 90 days was 17.41% (675). The mean length of stay per readmission was 8.8 days (95% confidence interval, 8.2-9.3 days), and the mean interval between discharge and readmission was 25.6 days (95% confidence interval 23.4-27.7 days). Each of these 675 readmissions was evaluated as planned or unplanned, and if unplanned, whether this readmission was directly related to the principal procedure. PRINCIPAL FINDINGS: Each of the 15 principal procedures was associated with a multiplicity of reasons for readmission, however, within each procedure a singular "stand out" event occurred, i.e. colorectal surgery, abdominal/pelvic abscess, carotid endarterectomy, hematoma. These "stand outs" are used to assign performance indicators designed to track these larger groups of patients for overall outcomes. CONCLUSION: Analysis of high volume surgical procedures can be streamlined using performance indicators derived from readmissions analysis. IMPLICATIONS OF POLICY, DELIVERY OR PRACTICE: Hospitals which currently use clinical pathways can incorporate procedure specific performance indicators to monitor outcomes, streamline clinical pathways, prevent early discharge, and avoid untoward events.  (Abstract by: Author)

     7.    Papatheofanis, F. J., Dickinson, B. D., & Matuszewski, K. A. ([s.d.]). Evaluation of suspected deep vein thrombosis [abstract]. Annual Meeting of International Society of Technology Assessment in Health Care, 12, 45.
Abstract: INTRODUCTION: The optimal clinical evaluation of suspected deep vein thrombosis (DVT) remains uncertain. Some institutions have developed critical pathways and practice patterns for improving the efficiency and quality of care for patients with suspected DVT. The development of critical pathways that incorporate multidisciplinary guidelines and wide applicability criteria remains controversial and standardization of care may provide physicians with the information required to tailor management decisions to individual patients. METHODS: A technology assessment was completed according to the evaluation criteria of the University HealthSystem Consortium. Seventy member institutions were surveyed regarding their practice patterns for the evaluation of suspected DVT. Approximately 60% of the institutions responded to the survey. RESULTS: Over 95% of academic medical centers do not have critical pathways for the evaluation of patients with suspected DVT. An ultrasound-based diagnostic pathway resulted in the most efficient and effective evaluation of suspected DVT. CONCLUSION: Several recommendations emerged from this assessment and survey of member institutions: 1) duplex ultrasonography (DUS) should be available for the rapid assessment of suspected deep vein thromboembolism; 2) equivocal results obtained from DUS should be followed by the performance of contrast venography; 3) acute lower extremity DVT, which has been diagnosed by objective methods, should be treated immediately with heparin in uncomplicated cases; and 4) institutions may provide more expeditious and consistent evaluation and treatment of suspected DVT when clinical guidelines are available and implemented.  (Abstract by: Author)

     8.    Niles, N. ([s.d.]). Creating a patient-centered culture: an industry-based, customer-centered approach using qualitative and quantitative research methods [abstract]. AHSR & FHSR Annual Meeting Abstract Book, 11, 79-80.
Abstract: PROBLEM AND OBJECTIVES.  Adoption of patient-centered care strategies can involve sweeping organizational transformation which may be resisted by many employees.  Moreover, such strategies must be successfully integrated into other patient care initiatives such as critical pathways and continuous quality improvement (CQI).  This paper represents an initial experience with an industry-based, customer-centered approach to cultural change integrating a patient-centered care strategy and CQI within a cardiac services group (Cardiology, Cardiac Surgery, and Cardiac Care).  DATA AND METHODS. Target services (open heart surgery and percutaneous transluminal coronary angioplasty :PTCA:) were selected and the services flow-charted in terms of patient "experiences".  Focus groups were convened to determine key quality characteristics "in the voice of the patient" which were used to develop a quality measurement survey. A population of 100 consecutive former patients (status post open heart surgery or PTCA) were surveyed. Analysis of survey results provided an indirect measure of patient "delight" and "disappointment".  Survey results were publicized with open meetings and a newsletter.  The input of "front-line" caretakers was invited for QI efforts as well as modifications of the measurement tool.  RESULTS AND CONCLUSIONS.  1) Six key quality characteristics emerged:  Caring, Comfort, Certainty, Convenience, Communication, and Cost.  2) Different quality characteristics were important at different patient "experiences."  3) Baseline patient perception of quality was 78% of maximum achievable or 45%, 42%, and 13% for delighting patients, meeting patients expectations, and disappointing patients, respectively.  4) The survey results were powerful motivators for "front-line" caregivers whose efforts were focused on specific "experiences".  It's concluded that an industry-based customer-centered approach to CQI can promote patient-centered culture change.  This approach fosters a deeper understanding of the target services as seen "through the eyes of the patient" and provides a framework for motivating participation of front-line caregivers and initiating continuous quality improvement efforts.  IMPLICATIONS FOR AUDIENCE: The imlications of the study results and methods will be discussed as they relate to creation of a patient-centered culture within an institution or cardiac service group and the integration of patient-centered care efforts with CQI initiatives.  (Abstract by: Author)

     9.    Morrale, M., Farquhar, D., & MacKenzie, T. ([s.d.]). Evaluation of a care map for hospitalized patients with community acquired pneumonia (CAP) [abstract]. Abstract Book/Association for Health Services Research, 15, 186.
Abstract: RESEARCH OBJECTIVES: The drive to improve quality of health care while reducing costs has led many health care organizations across North America to employ standardized forms of care delivery known as CARE MAPS or CLINICAL PATHWAYS. Although such care delivery has become commonplace in surgical disciplines, little is known about its applications to patients with non-surgical problems. This paper describes the methods and results of a rigorous evaluation of the use of a CARE MAP for patients requiring hospitalization for CAP. Objective One was to identify any difference in health status and patient satisfaction scores between those patients receiving treatment under the CARE MAP to those who did not.  Objective Two was to determine if the implementation of a CARE MAP resulted in reduced resource consumption, compared to standard care without a CARE MAP. Objective Three was to identify those variables that influenced patient outcomes and health status. STUDY DESIGN: This evaluation entailed a comparison, over a six month period, of the care processes and outcomes of one group of patients admitted to a hospital in which a CARE MAP was in place, to a control group of patients admitted to a comparative hospital without a CARE MAP. Process variables included the number of diagnostic tests and consultations ordered. Outcomes of interest included length of hospital stay (LOS), re-admission rates, and patient satisfaction. Demographic and clinical data were collected prospectively from both sites through a patient chart abstraction. In addition, participants were asked to complete a RAND 36 item health survey, and Patient Satisfaction and Return to Normal Activities questionnaires one month after discharge. Intermediate outcomes included ICU admissions, hours of intravenous antibiotic therapy, and hours to defervescence. Analysis included Multiple Logistic and Linear Regression statistical techniques. PRINCIPAL FINDINGS: Univariate analysis reveals that there is no significant difference in LOS in Hours of IV therapy between the experimental and control groups. Despite this fact, the CARE MAP patients showed a faster return to normal temperature (37.5 C). Regression analysis, adjusting for process of care and patient severity of illness, including a CARE MAP coefficient, confirms the above statements. Analysis of Health Related Quality of Life and Patient Satisfaction outcomes reveals the CARE MAP had no detrimental impact on quality of patient care. In fact, multivariate regression analysis showed that the use of the CARE MAP was associated with a significant increase in patients' general health, social, and emotional well being scores in the RAND 36 Item Health Survey. CONCLUSIONS: Use of a CARE MAP appears to have a positive impact on patient quality of life does not result in an increase in adverse outcomes, length of stay, or resource consumption. Further research is needed to determine the cost effectiveness of CARE MAP use. RELEVANCE TO CLINICAL PRACTICE AND POLICY: Knowledge of the effect of patient characteristics and process of care on patient outcomes will help improve CAP care and development of future CAP CARE MAPS.  (Abstract by: Author)

   10.    Marchetti, M., Volpe, M., Damiani, G., Meneschincheri, G., Giustacchini, M., Alcini, E., Catananti, C., Cicchetti, A., & Vanini, G. ([s.d.]). Assessment of hospital health care by the clinical practice pathways method [abstract]. Annual Meeting of International Society of Technology Assessment in Health Care, 14, 79.
Abstract: OBJECTIVE: In all developed countries, hospitals are under significant pressure in order to decrease expenses by optimizing resources use. In this context, a Health Technology Assessment method is necessary for ensuring effective health care and costs reduction. Clinical Practice Pathways (CPPs) are a group of diagnostic and therapeutic activities confined to a specific diagnosis. The developmnt of these activities follows the clinical steps of patients' treatment and represent the theoretical model of clinical activities to obtain a perfect diagnosis and therapy. The aim of the study is to validate the CPPs method by application to a specific disease (Benign Prostatic Hyperplasia-BPH) in order to use it for analyzing and rationalizing specific hospital health care processes. METHODS: A clinical panel, by analysis of international guidelines and specific clinical experiences, detected criteria and steps followed in clinical approach for patients affected by BPH in order to define the theoretical clinical pathways. Data of 58 patients, admitted in a urological ward of a 1500 beds hospital in the first six months of 1996, were collected from medical records to discover the really performed CPPs. Then the really performed activities were compared with the theoretical model to assess differences beween expected and observed clinical practice. RESULTS AND CONCLUSIONS: The observation of a number of cases with equal CPP to theoretical models suggests the possibility of using these CPPs in clinical practice. Furthermore the results of our study showed more observed CPPs than expected ones. The additional observed CPPs didn't have one or more essential diagnostic tests and/or inappropriate treatment. These results have justified the introduction of CPPs methods as a systematic activity for assessing and improving of health care quality for 22 specific diseases selected on the basis of three main criteria: number of admitted cases, variability of length of stay and hospital mortality rates. The association of this method with analysis of resources consumption for the different observed CPP is going to assure, at the same time, a high quality level of supplied hospital health care and an appropriate use of resources for specific diseases.  (Abstract by: Author)

   11.    Maojo, V., Lazaro, P., & Crespo, J. ([s.d.]). Effective dissemination of clinical practice guidelines over Internet [abstract]. Annual Meeting of International Society of Technology Assessment in Health Care, 13, 93.
Abstract: OBJECTIVES: To develop a computer model to represent, store, and disseminate clinical practice guidelines (CPGs). We address several problems related to such computer-based representations, including: (1) checking inconsistencies; (2) cost of dissemination; (3) updating to accommodate new medical knowledge; (4) local adaptation to different clinical settings; (5) feedback to developers; and (6) connection to other sources of information, such as medical records or multimedia systems. METHODS: We have created a specification language to represent CPGs graphically as flowcharts, and various C++ and JAVA-based computer tools for multimedia display and edition of electronically stored CPGs. The flowcharts have 4 kinds of nodes: Action, Clinical State, Decision and Advice. Our model integrates a standard proposed by the Society for Medical Decision Making and CPG representations developed by groups from the Agency for Health Care Policy and Research (AHCPR) and RAND. CPGs can be stored in a computer server using various commercial databases. Users can retrieve these guidelines over the World Wide Web using any Java-compliant browser. RESULTS: Users can navigate through the algorithm, with different browsing, abstracting and zooming techniques, and contract or expand nodes. They can access descriptive text, tables, pictures, video and sound, linked to the flowchart boxes. Algorithms can be authored and locally modified, changing nodes, arcs, contents, and multimedia links, to adapt to specific clinical circumstances. We have used AHCPR's heart failure guideline to evaluate the performance of our tools. CONCLUSIONS: Our approach facilitates translation of CPGs from paper to computer-based flowchart representations, solving some of the traditional problems mentioned above. Using this approach, guidelines and protocols can be integrated into medical information systems. Thus, they can be used to reduce variability in medical practice, increase quality of care, and reduce costs. Our model can be easily adapted to other technologies such as appropriateness criteria and critical pathways.  (Abstract by: Author)

   12.    Holmboe, E. S., Meehan, T. P., Radford, M. J., Wang, Y., Petrillo, M., & Krumholz, H. M. ([s.d.]). Hospital response to a state-wide Medicare quality improvement initiative [abstract]. Abstract Book/Association for Health Services Research, 15(184-185).
Abstract: RESEARCH OBJECTIVES: Peer Review Organizations (PROs) are responsible for monitoring and improving the quality of care received by Medicare beneficiaries in their designated area. The response of hospitals to PRO initiated quality improvement projects is not well characterized. This paper examines the impact of the 1992-93 Cooperative Cardiovascular Project (CCP) pilot among all 32 non-federal hospitals in Connecticut to improve the care of Medicare patients with acute myocardial infarction (AMI). STUDY DESIGN: Baseline data on mortality and process of care indicators for AMI were abstracted from 32 Connecticut hospitals as part of the 1992-93 CCP. Hospitals were encouraged to use this baseline data to target improvement initiatives for AMI care. The Connecticut Peer Review Organization (CPRO) asked each hospital to submit a Quality Improvement Plan (QIP) to specifically outline their process of care targets. The CCP follow-up study was done in 1995 to assess changes in AMI care in CT. For the present study, a single investigator (ESH), blinded to the CCP results, travelled to all 32 hospitals and conducted on-site structured interviews with quality improvement staff involved with the CCP in early 1997. The detailed interviews sought to determine what AMI processes of care hospitals had targeted for improvement as a result of the 1992-93 CCP pilot, the quality improvement approaches used by hospitals to change AMI care, and the perceived role of the CCP in the quality improvement program at each hospital. PRINCIPAL FINDINGS: Only two of 32 hospitals stated that they did not target any specific process of care after receipt of the baseline CCP results. The most commonly targeted processes of care indicators chosen by hospitals were: receipt or timing of thrombolytic therapy (n=18/32, 56%); use of aspirin at admission, during hospitalization, or at discharge (n=18/32, 56%); use of beta-blockers at admission or discharge (n=9/32, 28%); use of angiotensin converting enzyme (ACE) inhibitors at discharge (n=9/32, 28%); and smoking cessation counseling (n=11/32, 34%). The median number of indicators chosen by each hospital was 4. All hospitals felt they had improved between the 1992-93 and 1995 data collections. Overall, marked improvements were seen in the outcomes of 30-day mortality and length of stay in the 1995 follow-up study, but more modest improvements were noted in processes of care: timing of thrombolytics, receipt of aspirin during hospitalization and at discharge, and beta-blockers prescribed at discharge. The other indicators did not change between 1992-93 and 1995. We next examined process of care indicators with at least 10 observations at the hospital for both 1992-93 and 1995. Indicators specifically targeted by the hospital for improvement after the 1992-93 baseline study were more likely to show improvement in 1995 (34/45 processes of care, 76%) versus non-targeted indicators (53/84 processes of care, 63%), but the difference was not statistically different (P<.10). The approaches used by hospitals to bring about improvement in AMI care included identification of a physician champion/opinion leader (n=12/32, 38%), creation of standard order sheets (n=11/32, 34%), creation of multi-disciplinary teams (n=10/32, 31%), or creation of critical pathways for AMI (n=10/32, 31%). Critical pathways have recently been touted as a superior method to improve care. However, neither critical pathway nor any of the other approaches were superior in improving the use of thrombolytics, aspirin, beta-blockers, or ACE inhibitors. Finally, hospitals were asked specifically what role the CCP played in their AMI improvement program. Twenty-six hospitals responded that the CCP had played a useful role. The most commonly cited roles were: the data was important for BENCHMARKING against other hospitals (n=10/32, 31%); the CCP provided an important IMPETUS/CATALYST for change (n=10/32, 31%); and the 1992-93 data helped the hospital FOCUS on areas needing the most improvement (n=9/32, 28%). CONCLUSIONS: The role of a state-wide quality improvement project for AMI, the CCP, was highly variable among a cohort of 32 hospitals. The most important perceived values of the project were the availability of comparison data to "benchmark" against similar types of hospitals, provide impetus for change, and help hospitals focus their improvement efforts. Modest improvements were noted in the use of proven medical therapies for AMI. Several strategies were used by hospitals to effect improvement but no one strategy was superior in improving the use of proven medical therapies in Medicare AMI patients. Additional multi-institutional studies are needed to identify optimal strategies to produce improvement in clinical care.  (Abstract by: Author)

   13.    Hedley, A. J., Hardie, R. M., & McGhee, S. M. ([s.d]). Evaluation of tuberculosis care in a multi-sector service [abstract]. Annual Meeting of International Society of Technology Assessment in Health Care, 13, 86.
Abstract: BACKGROUND: Hong Kong has a typical multi-level, multi-sector health care system with many interfaces. The development of methods for continuous evaluation of the quality and outcome of care is essneital if services for treatment and  population control of a disease such as tuberculosis (TB) are to be cost-effective. SETTING: TB notification register, hospital, chest clinic, private practice and other records and sources of information (surveyed over a one year period) for a cohort of 454 patients notified in a one month period. FINDINGS: The data retrieved from multiple sources was complex. Audit of different information sources indicated that under notification of TB occurred in 10%. In those notified health care activities generated 2012 episodes of care: median per patient 4 episodes. There were 16 groups of health care facilities, comprising 140 different providers of which 38 (27%) provided care for 1743 (87%) of the episodes; 73% of providers covered 13% of the episodes. 1815 (90%) episodes could be abstracted from records but information about the others had to be derived from different sources. Information on at least 1 in 20 episodes was lost because the record or source of care could not be found or the information was incomplete. There was wide variation in the amount of medical work carried out for different members of the sample. 62% experienced one or more hospital admissions, 32% of these had 3 to >10 admissions. 95% had between one (21%) to six (4.2%) ambulatory episodes. 69% completed prescribed treatment and follow-up in the survey period but 15% were lost to follow-up before (0.4%), during (7.4%) or after treatment (7.0%). CONCLUSIONS: The notification-episode-care map can be used to identify (i) problems of communication and information management; (ii) possible approaches to rationalising provision of care; (iii) designs for a clinical information system to coordinate, monitor and audit care across the system.  (Abstract by: Author)

   14.    Farquhar, D., Morreale, M., & MacKenzie, T. ([s.d.]). Evaluation of a care path for community acquired pneumonia inpatients [abstract]. Abstract Book/Association for Health Services Research, 14, 104-105.
Abstract: SUMMARY: Due to increased pressure to improve quality of health care while reducing costs, many health care organisations in North America are employing standardised forms of care delivery known as Care Paths, and Clinical Pathways. Unfortunately, most of the literature fails to demonstrate the effectiveness of these guidelines through a formal evaluation with the use of controlled evaluation techniques involving comparable cohort groups and rigorous analysis involving standardised techniques and questionnaires. This presentation will describe the methods and results of a rigorous evaluation of a Care Path for patients requiring hospitalization for community-acquired pneumonia (CAP). RESEARCH OBJECTIVES: 1) Identify any difference in health status and patient satisfaction scores between those receiving treatment under the Care Path with a comparative sample who did not. 2) Determine if the implementation of a Care Path results in a decrease in patient resource consumption, compared to a control hospital site without a Care Path. 3) Identify variables that influence patient outcomes and health status. STUDY DESIGN: This evaluation entailed a comparison of the care processes and outcomes, over a five month perior (Nov 96 - April 97), of Care Path patients to those admitted to a comparator site without a Care Path. Outcomes of interest include health status, length of stay (LOS), re-admission rates and patient satisfaction. Analysis includes Multiple Linear Regression statistical techniques. PRINCIPAL FINDINGS: Preliminary results reveal that patients placed under the Care Path have a lower average LOS and mortality rate. Final results will be ready shortly and will be presented at the conference. CONCLUSIONS: Although results regarding quality of care and LOS are preliminary, there is a consensus among the staff members that care plans are a useful tool to integrate complex patient care services across levels of care within an integrated hospital care system. This process of integration in turn encourages the use of evidenced based medicine in hospitals, as well as cooperation and consensus. RELEVANCE TO CLINICAL PRACTICE AND POLICY: Standardised care processes for specific patient groups are becoming more important because of the need to reduce cost without compromising the quality of health care. The empirical nature of the clinical treatment of CAP presents a significant challege to produce an effective Care Path tool. This study will help to determine if a Care Path has any significant effect on the quality of care and resource consumption for the nonsurgical case mix group of community-acquired pneumonia (CAP).  (Abstract by: Author)

   15.    Cohen, W. ([s.d.]). An assessment of the Medicare Health Care Quality Improvement Program [abstract]. Abstract Book/Association for Health Services Research, 14, 173-174.
Abstract: RESEARCH OBJECTIVE(S): To quantify and demonstrate the impact of the Medicare Health Care Quality Improvement Program (HCQIP) through analysis of a sample of individual quality improvement projects in two critical areas. STUDY DESIGN: We abstracted data from a sample of individual quality improvement projects to reveal both the characteristics and effects of the overall Medicare Health Care Quality Improvement Program. A multidisciplinary task force chose two clinically relevant, highly prevalent, and costly medical conditions (the management of warfarin or aspirin in patients with atrial fibrillation and the management of community-acquired pneumonia). An abstraction instrument was piloted on 10 projects from 4 Peer Review Organizations (PROs)/Quality Improvement Organizations (QIOs). Consequently, two data abstraction tools were used (an initial survey and a follow-up which contained a subset of questions from the initial one) to obtain information on the impact of the PROs/QIOs and HCQIP via outcomes, organizational changes, or changes in the processes of care. A total of 72 quality improvement projects were initially identified for this assessment. Documentation for 68 projects (95% response rate), from 32 PROs/QIOs was received. PRINCIPAL FINDINGS: PROs/QIOs have engaged in approximately 1,000 quality improvement projects. This assessment focused on two clinical areas and found that there were some provider behavior changes as a result of the quality improvement projects. Study data were derived primarily from existing narrative project documents and project initiation reports as well as limited questionnaires. Several system changes were found that led to improvements in care. For example, many hospitals created or revised standing orders, checklists, or clinical pathways as a result of participating in a quality improvement project. In other instances, quality improvement projects were adopted by other organizations for non-Medicare populations, and length of stay, morbidity, and mortality were reduced. The results of this assessment were limited due to the infancy of the Health Care Quality Improvement Program (initiated in 1992). CONCLUSIONS: We have developed a generic survey instrument for obtaining useful information on the PRO/QIO quality improvement projects. The assessment discussed in this report can be viewed as a "pilot" of some of the methods one might use in evaluating the impact of these projects and should not be viewed as an ideal assessment. At this juncture, however, we believe this current study serves to identify some of the strengths and weaknesses of the PRO/QIO quality improvement process. Future enhancements to Health Care Quality Improvement Program will allow for a more complete evaluation of the current benefits of HCQIP to the Health Care Financing Administration (HCFA) and the entire United States health care delivery system. RELEVANCE TO CLINICAL PRACTICE AND POLICY: While not the major focus of this study, preliminary analysis suggests that the significant potential for the benefits of HCQIP projects outweighs the cost. The techniques and methods for an economic analysis are well developed in the health economics and health services research literatures, and should be included, when feasible, in all future HCQIP project evaluations. The Task Force recommended that HCFA and the PROs/QIOs conduct cost effectiveness analyses (e.g., identify benefit measures/quality indicators) as part of their future quality improvement projects. Although there is presently no mechanism to measure whether the HCQIP improves economic efficiency, it is likely that the potential benefits of the atrial fibrillation and pneumonia projects far outweigh their costs.  (Abstract by: Author)

   16.    Cloutier, M. A., Leverton, I. H., Golenski, J. D., & Sonnad, S. ([s.d]). A study to introduce methods of estimating cost of new technologies [abstract]. Annual Meeting of International Society of Technology Assessment in Health Care, 12, 53.
Abstract: A study to introduce methods of estimating costs of new technologies was conducted for the Interregional New Technology Committee of Kaiser Permanente. The Interregional New Technology Committee was formed in 1987 to review and make recommendations of coverage decisions for new medical technologies. To evaluate the potential applicability of cost as an explicit variable, the committee estimated two previously approved technologies, prostate specific antigen tests and mammograms, to understand how costs as an explicit variable would influence a decision to adopt these technologies. Analyses were conducted measuring projected costs based on: 1) current algorithms or clinical pathways used to focus their use, and 2) actual utilization and cost(s) based on a limited number of regions. The results of the study produced unexpected findings: 1) mammograms appeared to be more cost effective in Kaiser Permanente, compared to cost analyses conducted in meta-analyses by institutional technology assessment efforts such as ECRI or OTA, 2) Costs for PSA tests significantly outweighed the benefits even though provision of PSA is widely available for indicated risk groups or available on request. When making policy level cost decisions for specific delivery systems, analyses based on projected costs modelled on the specifics of the delivery system are required. Meta-analyses by large technology assessment organizations are better used as benchmarks rather than representative of what costs might be in a particular organization.  (Abstract by: Author)

   17.    Carter, J. H., McColligan, E. E., Jones, W. T., Johns, M. L., & Ostroy, F. ([s.d.]). A requirements analysis for an information system which supports decision making in a managed care environment [abstract]. Annual Meeting of International Society of Technology Assessment in Health Care, 12, 41.
Abstract: The advent of managed care has placed a greater emphasis on the efficient use of medical resources. In particular, health care providers must begin to consider not only matters of diagnosis and therapy, but also those related to efficacy, cost, and long-term benefit. Current health care information systems are clearly not up to the task. We propose that next-generation health care information systems must meet new standards in the following areas: user interface, external interfaces, data storage and retrieval, and data analysis. Further, the requirements that will serve as the blueprint for the construction of these systems must be grounded in new ways of looking at the process of patient care; fully acknowledging the importance of provider practice habits, guidelines, critical pathways, and interfaces to clinical databases and electronic medical records.  (Abstract by: Author)

   18.    Brewer, C. S. ([s.d.]). Strategies for survival: registered nurse staffing in Western New York [abstract]. AHSR & FHSR Annual Meeting Abstract Book, 13, 159.
Abstract: RESEARCH OBJECTIVE: The purpose of theis study was to describe the staffing strategies and use of alternative personnel in Western New York (WNY) acute care hospitals. STUDY POPULATION: 34 WNY hospitals and 195 nursing units, in the urban counties containing the cities of Buffalo and Niagara Falls, and six other primarily rural surrounding counties. STUDY DESIGN: A two-part questionnaire for the hospital and individual units was mailed to all 34 WNY hospital nursing administrators. The response rate was 79% of hospitals (27 hospitals) and 87% of units (170/195 units) after two mailings and a reminder letter. Hospital, unit and staffing variables were examined with descriptive analyses. The major dependent variable, mean RN per-occupied-bed, was analyzed by Pearson correlation, and was regressed on several hospital characteristic and staffing variables. PRINCIPAL FINDINGS: Urban hospitals represented a disproportionate number of units. Most of the units were medical/surgical/gynecological (41.8%) or intensive care (20.6%). Of the rest of the units, 10% were intermediate care, 11.8% were maternity, and 12.4% were nurseries, rehabilitation, or substance abuse units. Ten hospitals had reduced the number of RN FTEs employed. The mean was .76 (SD.73) RNs per-occupied-bed. Regression results (Adjusted RR=.523, F=10.598) indicated that primary care nursing models, and intensive care, maternity and pediatric units were most likely to have a significantly higher RN per-occupied-bed ratio. Teaching status, case mix, and other variables indicating organizational responses to economic pressures, such as network membership and use of case management and care maps were not significant. CONCLUSIONS: Staffing survival strategies described in the literature, such as cross-training licensed staff, removing non-nursing tasks and using unlicensed personnel with upgraded training (UAPs) do not seem to be widespread in WNY. However, it is not clear if this is the result of the slower development of pressure from managed care organizations in WNY than other parts of the country. RELEVANCE: Awareness of actual staffing trends rather than what may be in the popular literature is essential in planning a reasoned course of action by administrators. The importance of this study is to compare staffing practices and use of non-traditional staffing in WNY to the rest of New York and similar states as they cope with the current economic environment.  (Abstract by: Author)

   19.    Brewer, C. S. ([s.d.]). Hospital and unit factors influencing registered nurse staffing in Western New York hospitals [abstract]. Abstract Book/Association for Health Services Research, 14, 208.
Abstract: RESEARCH OBJECTIVE: The major research objectives were: 1) to describe the kinds of non-traditional staffing and other strategies being used in Western New York (WNY) acute care hospitals and 2) analyze the hospital and unit factors influencing the R.N. per-occupied-bed ratio. STUDY DESIGN: Descriptive survey. STUDY POPULATION: 34 Western New York (WNY) hospitals. Data Collection: A two-part survey was sent to the chief nursing executive at all 34 WNY hospitals. The response rate was 76.5% (26 hospitals). Of the 186 units in the respondent hospitals, 182 returned surveys (97.9%). Methods of analysis: Current staffing trends and the use of non-traditional staff in WNY were summerized with descriptive statistics. The major dependent variable, mean R.N. per-occupied-bed, was regressed on a number of hospital and staffing characteristics such as type of unit and staffing model, use of care maps and case managers, and hospital size, location, teaching status, length of stay, case mix and network membership. PRINCIPAL FINDINGS: Case management and care-map strategies are underway. Ten hospitals had reduced the number of R.N. FTEs employed by a mean of 9.84 R.N. FTEs. The mean was .73 (SD 1.13) R.N.s per-occupied-bed. Only 4 hospitals used unlicensed assistive personnel (UAP); R.N. performed many unskilled tasks. There was minimal use of other licensed or technical staff assigned to nursing units (e.g. respiratory therapists, occupational therapists). Regression analysis (Adjusted R2=.597) indicated that ICUs, primary care units, rural hospitals and use of nursing aides all increased the R.N. per-occupied-bed ratio. Use of unit secretaries decreased R.N. staffing. Variables indicating network membership, potential responses to managed care, or case mix were not significant. CONCLUSIONS: Staffing strategies described in re-engineering, such as use of UAPs, were not widespread in WNY. Real differences in staffing existed across unit and hospital types; the data indicated that R.N.s and Aides were complementary labor sources and LPNs and unit secretaries were substitute labor sources. RELEVANCE TO MANAGEMENT AND POLICY: Re-engineering may not be as widespread as the literature suggests. Evidence of response to the economic climate did exist in reduced R.N. staffing. Structural factors explained much of the variance in staffing, but much research is still needed, especially in tying staffing to outcomes. Rural hospitals in particular may need to examine staffing strategies to stay competitive.  (Abstract by: Author)

   20.    Brawer, M., Parson, R., Costa, M., & Scheil, B. ([s.d.]). Assessing the financial impact of serial PSA testing in managed care organizations [abstract]. Annual Meeting of International Society of Technology Assessment in Health Care, 13, 161.
Abstract: OBJECTIVE: To determine the financial impact on a managed care plan of ten years of serial prostate specific antigen (PSA) testing. METHODS: A longitudinal actuarial model was deigned to assess the per member per month (PMPM) impacts of digital rectal exam (DRE), and of DRE plus PSA testing, performed during an annual physical exam on a representative sample of managed care males aged 50-64. The model incorporates published clinical data, epidemiological data, and managed care payer information.  Model logic flow is derived from a clinical pathway that includes: testing, biopsy, and cancer detection rates; probable treatments by stage (watchful waiting, prostatectomy, radiation, hormonal treatment, orchiectomy); and terminal care. Major cost breakdowns are compared in terms of testing, treatment, monitoring, relapse and terminal care. Sensitivity analyses compare testing frequency, plan turnover rates, initial cohort cancer prevalence, and treatment mix assumptions. RESULTS: A shift to earlier stage cancers and a decreasiang number of terminal care patients result in variable incremental PMPM impacts. CONCLUSION: Actuarial modeling provides a useful approach to estimate real world impacts on managed care plans of adopting a PSA early detection policy. PMPM calculations may prove more useful to managed care plans in policy determination than other approaches; eg., cost-effectiveness studies.  (Abstract by: Author)

   21.    Borbas, C., McLaughlin, B., Germann, S., Morris, N., Boudlali, K., Lancer, S., & Schultz, G. ([s.d.]). Developing outcomes management evaluations and reporting programs for health care providers and purchasers: lessons learned [abstract]. AHSR & FHSR Annual Meeting Abstract Book, 11, 101.
Abstract: PROBLEM AND OBJECTIVE. The need for accessible, effective and efficient health care services has become a national priority in the United States.  Health care consumers, purchasers, providers and policymakers are all offering solutions.  Most of these plans rely to some degree on extensive clinical information, clinical guidelines, outcomes research and management, and continuous quality improvement programs which result in some type of comparative "report card" on all of this activity.  However, successful programs for both providers and purchasers have not been developed that result in assimilation and application of this information or behavior change.  DATA AND METHODS. This paper describes a clinical information program in Minnesota developed to assist a provider group's internal CQI programs and the needs of a purchasers coalition.  The organizations involved are the Prudential Plus program, the Employers Association and the Healthcare Education and Research Foundation.  The core components of the program are guidelines and clinical pathways combined with a data collection and reporting program (indications, process and outcomes and information). Both medical record and patient-generated data are collected. Standardized tools involved are the SF-36 and appropriate Spec Types and the GHAA Patient Satisfaction instrument.  The Greenfield Co-Morbidity Index is used to address case-mix differences. Pathways and outcomes measures have been developed for PTCA, Cardiac Catheterization, Hysterectomy, CABG, Substance Abuse, and 24-hour OB Stay.  Evaluations have been analyzed by hospitals but are now being developed for Integrated Services Networks (ISN).  RESULTS AND CONCLUSIONS: Due to lack of controlled studies, no causal relationships can be drawn between this program and changes in care; however, preliminary positive results are being reported.  Several data acquisition challenges continue but are being addressed.  IMPLICATIONS FOR AUDIENCE: Health care providers and purchasers can and must work together to effectively and efficiently accomplish their mutual objectives to provide and receive effective and efficient health care services.  The challenges are significant but all stakeholders can offer significant expertise and resources to begin to change the health care delivery system.  (Abstract by: Author)

   22.    Blegen, M. A., Reiter, R., & Goode, C. ([s.d.]). Outcomes of hospital based managed care: cost and quality [abstract]. AHSR & FHSR Annual Meeting Abstract Book, 11, 115.
Abstract: PROBLEMS AND OBJECTIVES. The purpose of this study, supported by a grant from AHCPR, was to determine the effects of Hospital Based Managed Care on the costs and quality of care provided to cesarean section patients at a tertiary care hospital.  Hospital based managed care is the use of locally derived multidisciplinary practice guidelines (CareMaptm) and a nurse case manager to facilitate the creation and implementation of these guidelines. DATA AND METHODS. A before-after design was used to determine the effects of this change in delivery of care method.  The data used for this study came from multiple sources: administrative data for length of stay, costs, and case-mix indicators; patient questionnaires and interviews for quality of care and physical recovery; and demographic data from patient's charts and interviews.  All patients who had cesarean sections during the study were included (181 before implementation and 154 after).  RESULTS AND CONCLUSIONS. The study groups were similar in age, gravidity, social, personal and clinical characteristics, and in case-mix indicators (presence of complications or co-morbid conditions).  Comparison of means across groups revealed differences that were in the expected direction and statistically significant for length of stay (-.73), cost (-$518), and patient reports of quality of care (4.26 to 4.41).  Physical recovery reported at discharge did not differ; but the physical recovery score at one month post-discharge was lower for the experimental group.  This decrease in perceived recovery was not supported by the prevalence of specific problems during the month after delivery as this did not differ.  The effect of Hospital Based Managed Care, controlling for case-mix, remained significant for costs and length of stay.  The change in quality of care scores was still positive but no longer statistically significant. IMPLICATIONS FOR AUDIENCE: The goal of reducing resource use while maintaining or even improving quality of care can be met with the use of locally derived multidisciplinary guidelines facilitated by nurse case managers.  (Abstract by: Author)

   23.    Balicki, B., Murphy, R., & Papazian-Boyce, L. ([s.d.]). Patient centered care methods and outcomes: an analytical review [abstract]. AHSR & FHSR Annual Meeting Abstract Book, 11(71).
Abstract: PROBLEM AND OBJECTIVES.  This paper presents findings from an ongoing study evaluating the outcomes of patient centered care and case management strategies for 27 hospitals in New York.  The project was designed to answer questions regarding tools and techniques used to effectively implement successful projects, as well as barriers which require minimization.  Additional study objectives were to identify the extent of cost and quality benefits derived from patient centered care as well as strategies necessary for sustaining and replicating program results. DATA AND METHODS.  The study population involved 27 hospitals who initiated a variety of projects in July 1991.  Over the next three years data was collected for Baseline, Year 1 and Year 2 analysis and trending.  The study utilized the following data for its analyses: Productivity--work sampling, timeliness of service, turnaround time, volume trends and FTE complement; Cost: nursing unit, patient, ancillaries: Outcomes--LOS, readmission within 30 days, ER visit within 7 days; Quality: critical pathway variance analysis, patient satisfaction, adverse incidents; Environmental--ALOS by DRG, occupancy, FTE:bed ratio, CMI (acuity), turnover, vacancy. RESULTS AND CONCLUSIONS.  In summary, the lessons learned from this study include: (1) most innovative models were implemented without the need for regulatory waivers; (2) many projects were put in place without a clear strategy for cost savings opportunities; (3) clinical resource efficiency can be achieved through the use of pathways without major changes in staffing operations; (4) reengineering and case management are distinct but interdependent strategies for improving productivity, efficiency and quality of care.  IMPLICATIONS FOR AUDIENCE: The implications of the study's results and methodologies will be discussedc particularly as they relate to preparing health care operations to meet the challenges and expectations of health care reform and managed care policies.  (Abstract by: Author)

   24.    Hampton, D. C. (1994). King's theory of goal attainment as a framework for managed care implementation in a hospital setting. Nursing Science Quarterly, 7(4), 170-3.
Abstract: Implementation of nursing conceptual frameworks and theories in practice settings is essential to foster the growth and advancement of the discipline of nursing. Over the past several decades nurse educators, administrators, and clinicians have often seemed to function in isolation. Educators developed conceptual models and theories, but these frameworks were infrequently applied in practice settings. In addition, administrators used management theories as a framework for nursing practice in institutional settings, while clinicians were left to utilize the medical model and theories from other disciplines as a base to guide practice. This article focuses on how King's theory of goal attainment can serve as a nursing framework for managed care.  (21 ref)

   25.    Ramos, T. (1994-1995). Elevating your net worth. Rt: the Journal for Respiratory Care Practitioners, 7(1), 9.

   26.    Daus, C. (1994-1995). A framework for team treatment: case management at Baptist Memorial Hospital. Rt: the Journal for Respiratory Care Practitioners, 7(1), 115-116, 118, 120.
Abstract: RTs were instrumental in developing some 400 critical pathways for patient care, which have quickened recoveries, lowered costs, and fostered staff collaboration

   27.    Thompson, D. G. (1994). Critical pathways: good idea, right reason? Critical Care Nurse, 14(6), 112.

   28.    Tahan, H. A., & Cesta, T. G. (1994). Developing case management plans using a quality improvement model... multidisciplinary action plan (MAP). Journal of Nursing Administration, 24(12), 49-58.
Abstract: Case management plans are viable tools currently used to control healthcare cost and improve quality. The authors present a quality improvement-case management framework to guide nursing and hospital administrators in the development of these plans and to answer any questions they might raise while struggling through the process.  (16 ref)

   29.    Sinnott, M. C. (1994). Critical pathways to success. PT--Magazine of Physical Therapy, 2(12), 55-63.
Abstract: Although critical pathways often are part of patient focused care, they don't have to be. They can be used as a TQM strategy in your own backyard. (2 ref 3 bib)

   30.    Reiling, J. G., & Baehr, L. J. (1994). Hospitals' newest challenge: designing in quality. Physician Executive, 20(12), 26-9.
Abstract: The job of producing high-quality products is even more difficult for health care providers than it is for those in manufacturing, where the quality movement began. As a part of the service industry, health care providers are in the position of producing products and delivering services at the moment of sale. Our task is to improve the quality of all of these simultaneous and interrelated processes. Traditionally, health care providers have made efforts to improve their products and services without realizing the impact that could be made by also improving resources, processes, and outcomes. This article is an overview of the new direction we have been taking: Retrospective review. Critical pathways. Building quality into all areas (resources, processes, products and services, and outcomes). Focused study of outcomes). We foresee a further evolution that will lead to exciting new methods for understanding and delivering high-quality care.  (Abstract by: Author)

   31.    Nugent, W. C., & Schults, W. C. (1994). Playing by the numbers: how collecting outcomes data changed by life. Annals of Thoracic Surgery, 58(6), 1866-70.
Abstract: The Northern New England Cardiovascular Study Group has been using clinical epidemiology to analyze outcomes data in patients undergoing cardiac surgical procedures to answer three questions: (1) for the surgeon: how am I doing?, (2) for the patient: what are my chances?, and (3) for society: can outcomes data be voluntarily collected and organized in a way to improve care delivery? The Dartmouth-Hitchcock Medical Center cardiac surgery program has combined this regional outcomes data with the internal development of critical pathways; with evaluations of patient expectations, patient satisfaction, and patient functional health; and with innovative techniques of data display in an effort to improve the cardiac surgical outcomes in patients at the center. The length of stay has declined, and both the mortality rate and readmission rate have remained stable

   32.    Newell, B. A. (1994). Taking charge: our new system makes nurses better teachers. RN, 57(12), 21-22,24.

   33.    Lynam, L. (1994). Case management and critical pathways: friend or foe? Neonatal Network, 13(8), 48-9, 51.

   34.    Knudtson, D. J., & Tobiasz, R. (1994). Practice guidelines: salvation for the emergency department. Journal of Emergency Nursing, 20(6), 450.

   35.    Kingsland, S., Smith, P., & McKinley, S. (1994). Introduction of managed care plans in a cardiac surgery unit. Contemporary Nurse: a Journal for the Australian Nursing Profession, 3(4), 189-94.
Abstract: Changes to output-based funding for health care as occurred recently in Victoria, and the goal of continuous improvement in quality of care, have provoked a rationalization of resource utilization and a greater focus on the process and outcomes of care in acute hospitals. The use of clinical management plans (CMPs) to monitor the efficiency of processes and the achievement of outcomes (managed care systems) is one approach to these challenges. A pilot study undertaken in the cardiac surgical unit at the Royal Melbourne Hospital is used to highlight the major considerations that need to be addressed when administering CMPs. These were the multidisciplinary, patient-focused approach of the managed care system, integration of the plans into the patient documentation system and the opportunities offered to research by variance analysis.  (7 ref 9 bib)

   36.    Everett, L., Tonkovich, O., Bania, K., & Richer, S. (1994). CRITICAL PATH NETWORK. Collaborative plan helps oncology unit meet new LOS demands. Hospital Case Management, 2(12), 201-4.

   37.    Elizondo, A. P. (1994). Nursing case management in the neonatal intensive care unit. Part 1: Pioneering new territory. Neonatal Network, 13(8), 9-12.
Abstract: Nursing case management is a model of care delivery that focuses on achieving optimal patient outcomes in expected time frames while containing costs. This is accomplished through a multidisciplinary team approach, guided by a multidisciplinary care plan, called a critical pathway. This model of care meets the standards of regulatory agencies and is in line with health care reform activities at the federal level. It should be considered as an effective, new way to provide care in the NICU

   38.    Dancer, S. E., & Logsdon, K. (1994). Patient trajectory: improving care for the radical retropubic patient. Urologic Nursing, 14(4), 151-4.

   39.    Sperry, S., & Birdsall, C. (1994). Outcomes of a pneumonia critical path. Nursing Economics, 12(6), 332-9, 345.
Abstract: Research outcomes of a pneumonia critical path for 73 patients in a metropolitan New York City hospital were analyzed. The positive outcomes included a decreased length of stay, decreased hospital charges, and improved multidisciplinary documentation

   40.    Smith, H. Q., & Buszta, C. (1994). Gaining acceptance in the use of critical pathways. Nursing Quality Connection, 4(3), 10-1.

   41.    Redick, E. L., Stroud, A. R., & Kurack, T. B. (1994). Expanding the use of critical pathways in critical care. Dimensions of Critical Care Nursing, 13(6), 316-21; quiz 322.
Abstract: Critical pathways are known to decrease the patient's length of stay while simultaneously using resources effectively and efficiently. Several additional functions of critical pathways exist: pathways are used as tools for teaching; to predict and prevent complications; streamline charting; and anticipate staffing needs. These and other functions of critical pathways are described as they apply to critical care patients

   42.    Redick, E. L., & Kurack, T. B. (1994). Marketing critical pathways in critical care. Dimensions of Critical Care Nursing, 13(6), 323-4.

   43.    Corbett, C. F., & Androwich, I. M. (1994). Critical paths: implications for improving practice. Home Healthcare Nurse, 12(6), 27-34.
Abstract: A critical path has been defined as a "written plan that functions as a map and timetable for efficient and precise delivery of health care." Critical paths are seen as a method of maintaining quality care while controlling costs through coordination of services. Many benefits have been realized through the use of critical paths in acute care settings. Despite their effectiveness in acute care settings, critical paths have received minimal attention in home healthcare. The purposes of this paper are to (1) illustrate the ways that home care can benefit from the use of critical paths; and (2) describe a process that home care providers can use to develop critical paths

   44.    Catherwood, E., & O'Rourke, D. J. (1994). Critical pathway management of unstable angina. [Review] [113 refs]. Progress in Cardiovascular Diseases, 37(3), 121-48.
Abstract: The critical pathway for UA is a multidisciplinary management tool designed to assist in expediting the treatment and evaluation of this frequent clinical syndrome. No critical pathway or practice guideline will meet the needs of all patients, and flexibility for patient variations and physician judgment is mandatory. Prediction tools and other facilitators cannot replace and must not impede the thoughtful assessment of complex clinical situations. Numerous factors, occasionally social or political in nature, impact on patient treatment strategies and the application of interventions. It is our hope that the Unstable Angina Critical Pathway will form a foundation for further innovation and cooperative effort toward optimizing the management of patients with acute ischemic syndromes. [References: 113]

   45.    Taylor, P. (1994). CRITICAL PATH NETWORK. Path for thromboembolism balances utilization and QM concerns. Hospital Case Management, 2(11), 183-6.

   46.    Quick, B. (1994). Integrating case management and utilization management. Nursing Management, 25(11), 52-56.
Abstract: Using a systems approach, critical pathways address different types of injuries in trauma patients. A 640-bed tertiary referral center contracted with an independent consultant to evaluate its trauma program, resulting in several improvements in the delivery of services. Case management achieved the action plan goals: improved utilization of resources, improved continuity of care, and decreased length of stay

   47.    Nozaki, T., Masutani, M., Akagawa, T., Sugimura, T., & Esumi, H. (1994). Suppression of G1 arrest and enhancement of G2 arrest by inhibitors of poly(ADP-ribose) polymerase: possible involvement of poly(ADP-ribosyl)ation in cell cycle arrest following gamma-irradiation. Japanese Journal of Cancer Research, 85(11), 1094-8.
Abstract: Low-dose gamma-irradiation of mouse embryonic fibroblast C3D2F1 3T3-a cells caused G1 arrest along with G2 arrest and inhibition of replicative DNA synthesis. When the cells were cultured in the presence of inhibitors of poly(ADP-ribose) polymerase [EC 2.4.2.30], such as 3-aminobenzamide, benzamide and luminol, G1 arrest of C3D2F1 3T3-a cells was suppressed and enhancement of G2 arrest was observed. In contrast, 3-aminobenzoic acid, a non-inhibitory analog of 3-aminobenzamide, did not suppress G1 arrest following gamma-irradiation. These results suggest that the poly(ADP-ribosyl)ation reaction is critical for the pathway of G1 arrest and is also involved in the pathway of G2 arrest

   48.    Lessner, M. W., Organek, N. S., Shah, H. S., Williams, C. A., & Bruttomesso, K. A. (1994). Orienting nursing students to cost effective clinical practice. Nursing & Health Care, 15(9), 458-62.
Abstract: Cost-related principles and associated learning activities have not been associated with cost-effective clinical practice.  (13 ref)

   49.    Gibson, S. J., & Thomas, L. (1994). Hospital saves $4.4 million with critical paths over 2 years. Hospital Case Management, 2(11), 188-192.

   50.    Ferdinand, M. (1994). Reducing orthopedic implant costs. A physician-driven approach at Mt. Sinai Medical Center, Cleveland. Journal of Healthcare Materiel Management, 12(11), 20-5.
Abstract: Faced with the closing of its service, the Orthopaedics Department at Mt. Sinai Medical Center, working with Materials Management, began a program to become profitable. Through standardization, appropriate utilization, pre-planning of cases and the development of critical pathways, the service has realized about 40% savings in materials and dropped their average product costs to $2,700 per joint and reduced length of stay by five to six days. The keys have been physician input from the start, teamwork and continuous training.  (Abstract by: Author)

   51.    Esler, R., Bentz, P., Sorensen, M., & Van Orsow, T. (1994). Patient-centered pneumonia care: a case management success story. American Journal of Nursing, 84(11), 34-38.
Abstract: Nurses in this hospital took the initiative in setting up a system that anchors case management squarely in the needs of the patient. With precise tools and clearly defined functions, they're helping patients recover quickly and confidently

   52.    DeWoody, S., & Price, J. (1994). A systems approach to multidimensional critical paths. Nursing Management, 25(11), 47-51.
Abstract: Using a systems approach, critical pathways address different types of injuries in trauma patients. A 640-bed tertiary referral center contracted with an independent consultant to evaluate its trauma program, resulting in several improvements in the delivery of services. Case management achieved the action plan goals: improved utilization of resources, improved continuity of care, and decreased length of stay

   53.    Musfeldt, C. (1994). Here's why critical pathways make sense for your practice. Managed Care, 3(10), 49-50.

   54.    Johnson, S., Nenov, V. I., Martin, N. A., & Becker, D. P. (1994). The neurosurgical intensive care unit in an era of health care reform. [Review] [32 refs]. Neurosurgery Clinics of North America, 5(4), 829-35.
Abstract: Health care reform, public concern, and managed care will create an environment that demands highly creative strategies to deliver quality care while reducing costs. Patient satisfaction and outcomes will take on a high priority. To meet this challenge, the neurosurgical ICU of the future will be designed with a patient-focused theme wherein the physical environment embodies healing and humanism. Services will be brought to the patient rather than the patient accommodating the system. Patients and families will be the directors of their own care. Staff and families will have access to a highly sophisticated clinical information system, and learning for staff at all levels will be a part of everyday life in the ICU. Unit management will be within a framework of shared governance wherein the power base is with the direct care givers, and decision and policy making happens at the point closest to the patient. Patient outcomes will be a result of a highly organized collaborative model that includes primary nursing, critical paths, and case management. Partnerships between nurses and unit support staff will create skill-mix changes that allow the nurse to spend less time on nonclinical unit maintenance-type functions and more time with the patient and family. This will have a positive fiscal impact as well as enhance patient satisfaction and outcomes. [References: 32]

   55.    Holman, B. L., & Seltzer, S. E. (1994). 'Critical paths' add value to practice guidelines. Diagnostic Imaging, 16(10), 63-5.

   56.    Frantz, A., & Medina, L. (1994). The cardiac care step-down unit at home. Caring, 13(10), 42-8, 51.
Abstract: Clinical pathways have proven to be the key to shortening hospital stays for cardiac patients, allowing them to move out of the hospital and back home sooner. These pathways have truly facilitated the paradigm shift from institutional to home care.  (15 bib)

   57.    Coen, S. D., & Silverman, E. (1994). Peripheral intra-arterial thrombolytic therapy for acute arterial occlusion. Critical Care Nurse, 14(5), 23-9.
Abstract: Because of the success of urokinase therapy, the expectation is that more patients with peripheral vascular disease will be treated with urokinase or another thrombolytic agent. For that reason, nurses must become proficient in caring for these patients. The standing orders and care map, along with the appropriate nursing diagnoses, offer the nurse concrete guidelines for the care of these patients

   58.    Bowen, J., & Yaste, C. (1994). Effect of a stroke protocol on hospital costs of stroke patients. Neurology, 44(10), 1961-4.
Abstract: OBJECTIVE: To determine the impact of a protocol on hospitalization costs for patients admitted with stroke. DESIGN AND SETTING: Nonrandomized control trial in an urban community hospital with 376 beds. PATIENTS: All patients admitted with a diagnosis-related group code of 014 (cerebrovascular disease) were included (N = 390). Patients with subdural hematoma (N = 2) or subarachnoid hemorrhage (N = 2) were excluded. INTERVENTION: A protocol for treatment of acute stroke was developed that included a critical path for nursing care, an algorithm for emergency department care, and suggested admission orders for physicians. MAIN OUTCOME MEASURES: The hospital information system computer database was searched for hospitalization charges, length of stay, tests performed, and treatments provided. RESULTS: Patients treated with the protocol had lower charges compared with historical (p = 0.026) and concurrent (p = 0.02) control groups. Lower charges were accounted for by a decreased length of stay in the protocol group compared with historical (p = 0.001) and concurrent (p = 0.13) controls. Tests and treatments provided were similar except that carotid Doppler studies and deep venous thrombosis prophylaxis were more frequently done in those treated with the protocol (p = 0.001 for carotid Doppler and p = 0.026 for deep venous thrombosis prophylaxis). There were no differences in outcome measures such as death or discharge disposition. Medical complications were similar in all groups. CONCLUSIONS: There were significant savings in hospitalization cost for patients with acute stroke after introduction of a treatment protocol. These savings were almost entirely related to decreased length of stay. The protocol led to modest differences in tests ordered and treatments provided

   59.    Giguere, M., & Lewis, M. (1994). The interdisciplinary team component of case management: a positive experience. CONA Journal Aciio, 16(3), 17-21.
Abstract: In this article the authors present the interdisciplinary team development of a hip fracture case management program. A description of the program and the perceptions of the team members regarding the impact of team work on their practice are also offered.  (22 ref)

   60.    Thomas, J., Miller, P., Silaj, A., & King, M. L. (1994). Application of physiotherapy outcome measures to the managed care model. Physiotherapy Canada, 46(4), 260-5.
Abstract: Managed Care (MC) is a multidisciplinary model for health care delivery that organizes and sequences the caregiving process. Its objectives include: 1) to reduce length of stay and resource consumption, and 2) to measure, maintain or improve patient outcomes related to care received. Our tertiary care facility is the first Canadian hospital to implement MC. Patient care is directed through the use of a Care Map. Each map is specific to a pathological state and its treatment, i.e. Total Knee Replacement (TKR), and consists of a Patient Problem List, with related patient-centred outcomes, and a Critical Path. The Critical Path outlines the temporal sequence of the provision of care. Most key events on a Care Map are determined anecdotally. The purpose of this project was to collect outcome information in patients assigned to the Total Knee Replacement Care Map in an attempt to validate the existing Care Map or make recommendations for revisions. Inter-rater and intra-rater reliability of knee range of motion-was calculated using the Intra Class Correlation Coefficient (ICC). ICC values ranged from .64-.97. Seventeen patients were assessed. All patients were measured on Day 6 and 8 of the Care Map. This process has resulted in validation of certain range estimates and recommendations for revision of others.  (Abstract by: Author)

   61.    Smith, G. B., Danforth, D. A., & Owens, P. J. (1994). Role restructuring: nurse, case manager, and educator. Nursing Administration Quarterly, 19(1), 21-32.

   62.    Johnson, D. (1994). Automation of the birth registry log book. Computers in Nursing, 12(5), 245-52.
Abstract: If available resources are limited, a computer novice with basic computer skills can develop and implement an electronic database management system. Commitment and determination to automate manual record keeping of birth registry data are crucial. Some of the database software systems available today were designed to be user friendly. Product reviews published in personal computer magazines will assist an end user to find such user-friendly programs. Once a system is selected and implemented, data can be easily retrieved and used for simple to advanced database functions. Hospital statistics, state-required maternity statistical reports, and research, quality assurance/quality improvement, staffing justification, market research, and critical path variance reports will benefit from the wide array of data manipulation techniques

   63.    Hunter, J. C. (1994). Commentary on Planning, implementing, and evaluating a chemotherapy critical path [original article by Hawkins J et al appears in J ONCOL MANAGE 1994;3(2):24-9]. ONS Nursing Scan in Oncology, 3(5), 17.
Abstract: The authors describe the process by which a multidisciplinary team collaborated to develop a clinical pathway for patients receiving any chemotherapy regimen requiring hospitalization from 1 to 5 days. Development of the pathway (a timeline of care from preadmission to discharge) included analyses of system delays that affected chemotherapy administration. A 6-month pilot study with the pathway conducted in 1989 demonstrated a reduced length of stay Subsequent revisions and implementation resulted in a decrease in both cost per case and length of stay. Continuous evaluations of the pathway and variances will provide a means to improve patient care

   64.    Geradi, T. (1994). A regional hospital association's approach to clinical pathway development. Journal for Healthcare Quality, 16(5), 10-4.
Abstract: Sixteen hospitals from the Northeastern New York Hospital Council tested the theory that clinical pathways are an essential component of the integrated quality assessment process. Clinical pathways served as a transition to the holistic, process-oriented approach of quality improvement. The clinical pathways that they developed included preadmission, hospitalization, and postdischarge care needs. Respect and trust established among the hospitals in the consortium were evidenced by the cooperation and collaboration of the participating hospitals. This regional approach to care resulted in increased patient and staff satisfaction, positive patient outcomes, and a decrease in length of stay. (Abstract by: Author)

   65.    Windle, P. E. (1994). Critical pathways: an integrated documentation tool. Nursing Management, 25(9), 80F-80L, 80P.
Abstract: A multipurpose six-page, three-fold flow sheet improves patient outcomes, meets JCAHO standards and facilitates easy tracking of a patient's progress. The flow sheet is divided into nursing process, expected patient outcomes, critical pathway and variance report. Outcomes management is an effective process to control costs and improve patient outcomes

   66.    Shikiar, M. S., & Warner, P. (1994). Selecting financial indices to measure critical path outcomes [corrected] [published erratum appears in NURS MANAGE 1994 Nov;25(11):14]. Nursing Management, 25(9), 58-60.
Abstract: The implications of using broad-based DRG data versus more specific clinical data must be presented when implementing a hospital-based case management program. Administrators and nurse managers must collaborate when defining and applying appropriate financial indicators and implementing critical paths. Knowledge of patient populations and case types addresses both quality and cost.  (3 ref 3 bib)

   67.    Schriefer, J. (1994). The synergy of pathways and algorithms: two tools work better than one. Joint Commission Journal on Quality Improvement, 20(9), 485-99.
Abstract: BACKGROUND: Clinical quality improvement efforts at the Medical Center Hospital of Vermont (MCHV) led to the development of critical pathways, which show the ideal plan of care, and algorithms, which help clinicians make one of many complicated decisions within a plan of care. A synergy appears to develop when pathways and algorithms are used together. DEVELOPMENT OF PATHWAYS AND ALGORITHMS: A steering committee supports and oversees pathway and algorithm efforts. A quarterly tracking report updating progress for all pathways and algorithms is circulated to all nurse managers, medical staff, and administrators. When combining pathways and algorithms, the pathway is created first. Algorithms are developed for trouble spots within a pathway. CORONARY ARTERY BYPASS GRAFT (CABG) PATIENTS: Having developed the pathway for CABG patients, the CABG case management team meets monthly to review outcomes and variances. For example, an algorithm for managing atrial arrhythmias--the chief cause of variance for one month's results--was developed. The combination of pathways and algorithms for CABG patients has resulted in a reduction of 2.5 days for total length of stay (including 1 day on the surgical intensive care unit [SICU]), for a mean cost savings of $3,500. Re-admission to the SICU, reintubation, and mortality rates have all decreased. CONCLUSION: The idea of reaping the benefits of both pathways and algorithms is becoming more popular at MCHV, where teams use algorithms to improve on complicated processes underlying the pathways

   68.    McCaffrey, S., & Nightingale, C. H. (1994). How to develop critical paths and prepare for other formulary management changes. Hospital Formulary, 29(9), 628-32-635.
Abstract: Changes occurring in the health care marketplace are changing the way clinicians are managing patients. Cost, quality, and efficiency of care are increasingly being focused upon. One patient care management strategy that keeps these three factors in mind and is growing in popularity is the use of critical paths. This article describes the 7-step critical path development process followed by clinicians at Hartford Hospital. Additionally, the effect of health care marketplace changes on the formulary decision-making process, P & T Committee structure and function, and new drug development is also presented.  (Abstract by: Author)

   69.    Lockhart, C., Mandel, J., Grossett, D., & Green, D. (1994). The paradigm shift: behavioral home care. Caring, 13(9), 10-1, 74-76.
Abstract: Home care agencies looking to compete in today's competitive market must learn to target their services to market niches and to keep their eyes on marketplace trends. This article examines the changes occurring in behavioral home care and how agencies can tailor their services to their communities.  (7 ref)

   70.    Inglis, W. L., Dunbar, J. S., & Winn, P. (1994). Outflow from the nucleus accumbens to the pedunculopontine tegmental nucleus: a dissociation between locomotor activity and the acquisition of responding for conditioned reinforcement stimulated by d-amphetamine. Neuroscience, 62(1), 51-64.
Abstract: Output of neuronal information from the nucleus accumbens to the ventral pallidum is known to be a critical pathway in the expression of locomotion and incentive-related behaviour. Some signals from this structure are relayed forward through the dorsomedial nucleus of the thalamus to the medial prefrontal cortex, but the other major pathway from this site is a descending innervation to the pedunculopontine tegmental nucleus. Information carried by these descending neurons has been linked with both the output of locomotor activity and incentive-related information. Previous studies carried out in this laboratory have shown no changes in locomotor activity--either spontaneous or in response to systemic administration of d-amphetamine or apomorphine--in rats with excitotoxic lesions of the pedunculopontine tegmental nucleus. The present experiments compare the effects of ibotenate lesions of this nucleus in tests of locomotor activity or the acquisition of responding with conditioned reinforcement, following injections of d-amphetamine directly into the nucleus accumbens. In general agreement with previous results, ibotenate lesions of the pedunculopontine tegmental nucleus did not alter locomotion stimulated directly from the nucleus accumbens. However, comparable lesions in a group of trained rats produced an array of deficits in the conditioned reinforcement paradigm. Most notably, these rats directed their attention almost entirely towards pressing the levers (practically ignoring the food-hopper panel), but did not appear to be able to discriminate between them, while controls focused almost all their efforts on pressing the reinforcing lever (virtually ignoring the non-reinforcing lever) and the food-hopper panel. These results indicate that pedunculopontine tegmental nucleus lesions disrupt an element of reward-related responding, but do not affect the production of locomotor activity. This highlights the unlikely existence of specific "locomotion-inducing" centres in the mesencephalon and implicates the pedunculopontine tegmental nucleus in the formation of stimulus-reward associations. These data are discussed with respect to a role for the pedunculopontine tegmental nucleus in response selection

   71.    Girard, N. (1994). The case management model of patient care delivery. AORN Journal, 60(3), 403-5, 408-412, 415.
Abstract: Case management is a model of care delivery that integrates patient and provider satisfaction and consideration of cost factors and provides a method of managing individuals' holistic health concerns. Using the case management approach, nurses can optimize client self-care, decrease fragmentation of care, provide quality care across a continuum, enhance clients' quality of life, decrease length of hospitalization, increase client and staff satisfaction, and promote cost-effective use of scarce resources. Case management offers nurses an opportunity to demonstrate their roles in multidisciplinary health care teams. Case management is relevant in ambulatory surgery settings and in the perioperative care of complex surgical patients.  (31 ref)

   72.    Eastes, L. E. (1994). Toward continuous quality improvement in trauma care. Critical Care Nursing Clinics of North America, 6(3), 451-61.
Abstract: Trauma providers are engaged in a constant struggle to improve quality and to assure positive outcomes in an unpredictable disease process. Traditional quality assurance has been unsuccessful in achieving these goals. Continuous quality improvement methodologies hold promise as the tools to balance quality, outcomes, and patient satisfaction with cost concerns.  (26 ref)

   73.    Cook, J. C. (1994). Clinical pathways improve organizational performance. QRC Advisor, 10(11), 1-5-6.

   74.    Benning, C. R., & Smith, A. (1994). Psychosocial needs of family members of liver transplant patients. Clinical Nurse Specialist, 8(5), 280-8.
Abstract: RECENT LITERATURE IS beginning to reflect the importance of psychosocial needs of liver transplant patients, examining functional outcome, quality of life, daily living, and psychiatric and neurocognitive outcome. Little attention has been paid to the psychosocial needs of the liver transplant patient's family or significant other. Family members, along with the patient, must cope with disease chronicity, an uncertain organ donor waiting period, role reversal, a protracted postoperative hospital course, and a complicated medical regimen after discharge. Consequently, demands on time, energy, finances, and relationships can strain an already stressed family structure. Psychosocial needs of the liver transplant patient's family are discussed in this article, including aspects of chronic disease, the transplant evaluation, the waiting period, the immediate postoperative period, and long-term adjustment and recovery. Nursing interventions to facilitate effective coping strategies are suggested. Gaps in the existing literature are identified and suggestions for future research are made.  (21 ref)

   75.    Zander, K., & McGill, R. (1994). Critical and anticipated recovery paths: only the beginning. Nursing Management, 25(8), 34-7, 40.
Abstract: Multidisciplinary outcome-based care plans are a powerful aid to clinicians in managed care and case management situations. After several years of using Anticipated Recovery Paths, a committee designed a Professional Practice Symposium focusing on the skills needed by nursing personnel to provide effective outcome-based practice. Results of this educational effort are reported.  (4 ref)

   76.    Veenema, T. G. (1994). The ten most frequently asked questions about case management in the emergency department. Journal of Emergency Nursing, 20(4), 289-92.
Abstract: Case management's time-framed "care maps," which can improve the consistency of care, ED data collection, and billing for ED procedures, can be adapted to ED care.  (4 ref 2 bib)

   77.    Patterson, P. (1994). Critical pathways. Hospital shortens cataract stays, boosts satisfaction. Or-Manager, 10(8), 19.

   78.    Keyzer, D. M. (1994). Expanding the role of the nurse: nurse practitioners and case managers. Australian Journal of Rural Health, 2(4), 5-11.
Abstract: This paper discusses the impact of health trends on the structure of nursing organisations and the function and education of the professional nurse. It is argued that these changes are promoting a demand for autonomous nursing practice in the form of nurse practitioners and nurse case managers. The challenge to the profession is viewed in terms of making current health policies work for the achievement of professional goals, rather than against them.  (19 ref)

   79.    Homan, C. (1994). CRITICAL PATH NETWORK. Five hospitals succeed with critical paths for psychiatric inpatients [corrected] [published erratum appears in HOSP CASE MANAGE 1994 Sep;2(9):154]. Hospital Case Management, 2(8), 135-8.

   80.    Fields, M. (1994). Critical pathways: high roads to better patient care. Healthcare Informatics, 11(8), 40-2-44.

   81.    Counsell, C. M., Guin, P. R., & Limbaugh, B. (1994). Coordinated care for the neuroscience patient: future directions. Journal of Neuroscience Nursing, 26(4), 245-50.
Abstract: A coordinated care model was developed on a neuroscience unit to achieve positive outcomes in a cost-effective environment. This included the development of a patient care coordinator (PCC) role, critical paths and a system for variance tracking. The PCC was responsible for coordinating care of patients and ensuring that patients progressed toward expected outcomes. Multidisciplinary critical paths were developed for four medical diagnoses. To evaluate the effectiveness of the program, an analysis of length of stay data, cost comparison, patient and staff satisfaction, and variance reports of one critical path, the microvascular decompression for trigeminal neuralgia were completed. Results from the pilot project were positive and provided valuable information for the use of coordinated care as a hospital-wide patient care delivery model

   82.    Bejciy-Spring, S. M., Neutzling, E., & Newton, C. (1994). Nursing case management: enhancing interdisciplinary care of the spinal cord injured patient. Sci Nursing, 11(3), 70-3.
Abstract: Comprehensive care of the person with a spinal cord injury (SCI) requires collaborative, coordinated, interdisciplinary care. It is imperative that the care provided by nurses, therapists, physicians, and ancillary personnel is organized and integrated in a holistic manner if optimal outcomes of rehabilitation are to be achieved. Nursing case management has been identified as an approach to health care delivery that provides quality, patient-centered care. The potential impact of this care delivery model on the health care system for persons with SCI includes quality rehabilitation outcomes, increased patient satisfaction, enhanced interdisciplinary relationships, and improved continuity of care from intensive care to community settings.  (14 ref)

   83.    Lumsdon, K. (1994). Continuum of care. Clinical paths: a good defense in malpractice litigation? Hospitals & Health Networks, 68(13), 58.

   84.    Lumsdon, K. (1994). Clinical paths: a good defense in malpractice litigation? Hospitals & Health Networks, 68 (13), 58.

   85.    Rozell, B. R., & Newman, K. L. (1994). Extending a critical path for patients who are ventilator dependent: nursing case management in the home setting. Home Healthcare Nurse, 12(4), 21-5.
Abstract: A case management model is prepared to extend nursing care of the patient who is ventilator dependent from the hospital to the home setting. The model focuses on decreasing the hospital length of stay and major critical pathway elements. Effective discharge planning is emphasized

   86.    Riley, S. A. (1994). Clinical pathways: a basic tool for subacute care. Nursing Homes, 43(6), 35-36.

   87.    Page, C. I. (1994). Commentary on Deploying patient-focused care in the emergency department [original article by Donovan M appears in LEADERSHIP MANAGE EMERG NURS 1993:2(10),3-18]. ENA's Nursing Scan in Emergency Care, 4(4), 11.
Abstract: SYNOPSIS: In this monograph, the author discusses the concept of patient-focused care (PFC) and its applicability to the ED setting. Workforce redesign and clinical case management are key to implementing PFC, which is believed to facilitate patient care and promote operational and economic efficiency. Other identified benefits include but are not limited to enhanced patient flow and timeliness of intervention, increased productivity and autonomy, empowerment of professional staff, and decreased care fragmentation. The reader is encouraged to discard traditional practice patterns and embrace PFC as an approach to providing episodic and emergency care in the future. Included are a chest pain critical pathway and job description for an emergency technician

   88.    Nugent, W. C., Niles, N. W. 2nd, Schults, W., Plume, S. K., Wolf, B. H., Tarbox, G. H., Robb, J. F., & Nelson, E. C. (1994). Increasing the value of cardiac care: the Dartmouth approach. Quality Letter for Healthcare Leaders, 6(6), 53-7.
Abstract: A cardiac services team at Dartmouth-Hitchcock Medical Center (DHMC) launched multiple efforts to improve the quality and value of their services. The team developed a critical path for coronary artery bypass grafting (CABG) and tracked important clinical outcomes, such as mortality rates and wound complications. The team also studied the patient's view of the process. Staff used focus groups and surveys to distill the "voice of the customer" into six quality characteristics and developed methods to better involve patients in clinical decision making and evaluation of treatment efficacy. Results: CABG mortality declined from 5.7 percent in 1992 to 2.7 percent in 1994, 16 months after the critical path was developed. Mean total intubation time for patients following open-heart surgery was reduced from 22 hours to 14 hours. Median postoperative length of stay decreased from seven days to six for elective CABG patients. The number of patients discharged in five days or less increased from 20 percent to 40 percent. Readmission to the hospital following discharge remained stable, despite the shorter length of stay.  (Abstract by: Author)

   89.    Mellott, S. K. (1994). Commentary on Collaborative care: a quality improvement and cost reduction tool [original article by Kimball L appears in J HEALTHC QUAL 1993;15(4):6-9]. Aone's Leadership Prospectives, 2(4), 21.
Abstract: Topic: The development and implementation of a clinical path for DRG 209, total joint replacement. Purpose: To demonstrate the use of a clinical path to decrease length of stay (LOS), to increase collaboration among healthcare team members, to provide coordinated outcome-oriented patient care, and to assure appropriate utilization of resources. Source: Physicians, nurses, and other members of the healthcare team jointly developed a clinical path for DRG 209, total joint replacement. The path is used for shift reports to relate the critical incidents scheduled for the day and the expected length of stay. The path becomes a part of the chart on admission to the hospital. Conclusions: Using the clinical path for DRG 209, LOS decreased 4.47 days with savings of $1,000 per case. Patients are now transferred to a hospital-based skilled nursing facility 2 days sooner. The collaborative healthcare team is currently examining variances for resolution. [Original article accession number: 1994187268 (care plan)]

   90.    Jones, R. A., & Mullikin, C. W. (1994). Collaborative care: pathways to quality outcomes. Journal for Healthcare Quality, 16(4), 10-3.
Abstract: In 1990, The Memorial Hospital at Easton, Maryland, Inc., a not-for-profit 183-bed rural community hospital, recognized a need to explore alternative patient care methods or approaches to improve the continuity of care, focus on healthier patient outcomes, and contain costs. The concept of collaborative care became the focus for patient care delivery. Multidisciplinary teams were established to coordinate patient care activities for patient populations process. Plans of care, referred to as critical pathways, identify intermediate goals and interventions, providing guidance for the patient, family, and healthcare providers as they work to achieve quality outcomes. As the patient progresses along the critical pathway, variances from the established goals are monitored and become the focus of quality reviews.  (Abstract by: Author)

   91.    Hunter, J. C. (1994). Commentary on Creating a managed care product for cancer services [original article by Franklin M appears in J ONCOL MANAGE 1994;3(1):19-26]. ONS Nursing Scan in Oncology, 3(4), 19.
Abstract: SYNOPSIS: The author chronicled the beginning efforts of one cancer center to develop a packaged program of services for managed care. Strategies for this program were based on a 10-step process that included basic components of continuous quality improvement (CQI). Flow charts were used to evaluate existing care and to plan desired services. A time line of expected activities is presented in a care-map format. At the core of this product line is the role of the case manager

   92.    Freda, M. C. (1994). Commentary on Short, shorter, shortest: improving the hospital stay for mothers and newborns [original article by McGregor LA appears in MCN 1994;19(2):91-6]. AWHONN's Women's Health Nursing Scan, 8(4), 12-13.
Abstract: SYNOPSIS: When postpartum stays were 3 to 5 days nurses had the time to observe new mothers as they developed a level of comfort with their newborns. They could teach new mothers how to care for themselves and for their babies. Now all that has changed and is unlikely ever to return. The difficult part of the equation is that nurses need to get used to the changes and to develop new methods of care that are satisfactory for both patients and nurses. At 24-hour discharge, mothers are wheeled out of the hospital no matter how exhausted they might be or how little they have learned about infant care in the hospital. The literature suggests that home visitation is the way to bridge this gap, but what is to happen when nurses and hospitals have no funding for such programs? At Alexandria Hospital in Virginia, nurses' morale was declining rapidly. Job satisfaction for nurses was low. They had no time to teach their patients and had to watch as they went home in 24 hours. The nurses formed critical pathway and case-management committees to examine how to solve the problem. Case management was found to be prohibitively expensive, giving critical pathways high priority. Nurses from labor and delivery (L&D), postpartum, and the nursery worked together to develop the critical pathways. Activity objectives made reference to "hour after delivery" rather than "day shift" or "day after delivery." Time frames were established for all nursing care to be accomplished during a 24-hour continuum. Nurses in L&D began to incorporate some nursing activities previously done in the newborn nursery (e.g., vitamin K injections, blood glucose assessments). Preprinted postpartum orders now reflected the 24-hour stay. Education began with a prenatal letter to the mother detailing the 24-hour mandated discharge and asking women to inquire from their insurance companies about coverage for home visits and breast pumps. Education on the postpartum unit focused on the essentials. Mothers were assessed for the information they needed the most and taught just that, which was difficult for nurses used to teaching a complete package of information. The perceived loss of the nurse-patient relationship with 24-hour discharge was the hardest part of the change for the nursing staff. Sessions with the psychiatric nurse liaison helped nurses understand their role was changing and that they needed to change with it. [Original article accession number: 1994186301 (forms)]

   93.    Clark, C. M., Steinbinder, A., & Anderson, R. (1994). Implementing clinical paths in a managed care environment. Nursing Economics, 12(4), 230-4.
Abstract: The survival of health care institutions depends upon a delivery system focusing on appropriate use of resources and controlling length of stay while monitoring clinical progress toward identified outcomes. Using a clinical path as a tool for managing resources, research activities, continuous quality improvement, and increased collaborative practice can enhance the professional practice environment and benefit patient care

   94.    Wiley, G. (1994). On a critical path... Emory University Hospital is positioning its Center for Rehabilitation Medicine to meet the demands of managed care. Rehab Management: The Interdisciplinary Journal of Rehabilitation, 7(4), 128-130,169.

   95.    Von Rotz, N. P., Yates, J. R., & Schare, B. L. (1994). Application of the case management model to a trauma patient. Clinical Nurse Specialist, 8(4), 180-6.
Abstract: Alternative models and patterns of health care delivery have emerged in order to decrease institutional costs and maintain quality of care. The case management model, an alternative health care delivery model, serves as a framework for the delivery of care to trauma patients with multiple injuries. In this article, we review delivery of care, the role of the case manager, and components of the case management model: selection of patient, health assessment, planning and coordination of care, monitoring, and evaluation of outcomes.  (20 ref)

   96.    Turley, K., Tyndall, M., Roge, C., Cooper, M., Turley, K., Applebaum, M., & Tarnoff, H. (1994). Critical pathway methodology: effectiveness in congenital heart surgery. Annals of Thoracic Surgery, 58(1), 57-63; discussion 63-5.
Abstract: Critical pathway methodology has been demonstrated to provide producible reduction in average length of stay (ALOS) in adults in certain diagnostic-related groups and operations such as coronary artery bypass grafting. The efficacy of this approach in congenital heart surgery was explored. Two hundred eighty-six consecutive patients from a health maintenance organization treated by a single surgeon since the institution of diagnostic-related group coding at that health maintenance organization constituted the study group. One hundred fourteen patients were treated at a university hospital without critical pathway methodology (group 1) and 172, subsequently at the health maintenance organization institution using the methodology (group 2). Operation/lesion, age, and diagnostic-related group matching was possible in 61 pairs. Examination of the ALOS Hospital (operative and postoperative days) for the entire cohort revealed a 43.8% reduction in ALOS Hospital (p < 0.0001) and a 39.0% reduction in ALOS Intensive Care Unit (p < 0.0001). There was also significant reduction in ALOS Hospital and ALOS Intensive Care Unit in the operation/lesion-matched subsets. Outcome measures including operative and late mortality, readmission, unscheduled emergency room and clinic visits, and health maintenance organization family assessment survey demonstrated no improvement in outcome with increased hospital stay. Thus, critical pathway methodology when used in patients undergoing a congenital heart operation produces a significant reduction in hospital stay and intensive care unit stay as well as quality patient care with uniformity of outcome

   97.    Patterson, P. (1994). Critical pathways... perioperative case managers redesign processes. Or-Manager, 10(7), 8-10.

   98.    Patterson, P. (1994). Critical pathways... care paths cut length of stay, reduce charges. Or-Manager, 10(7), 12.

   99.    Heacock, D., & Brobst, R. A. (1994). A multidisciplinary approach to critical path development: a valuable CQI tool. Journal of Nursing Care Quality, 8(4), 38-41.
Abstract: Many health care facilities are developing and implementing critical paths to streamline the provision of quality care. Critical paths are a compilation of multidisciplinary input driven by specific time oriented outcomes. The purpose of this article is to illustrate critical path development, utilizing a multidisciplinary approach in a community hospital setting. The creation of a critical path will be described, from the environment that stimulated interest, to development and implementation of the path. Advantages to the patient and members of the health care team are presented. Emphasis is placed on strategies that promoted and facilitated collaboration among team members

100.    Giffin, M., & Giffin, R. B. (1994). Critical pathways produce tangible results. Health Care Strategic Management, 12(7), 1-17-23.

101.    Gibson, S. J., Thomas, L., & Burnette, J. (1994). Atypical pathways sends mastectomy patients home early. Hospital Case Management, 2(7), 117-120.

102.    Dunn, J., Rodriguez, D., & Novak, J. J. (1994). Promoting quality mental health care delivery with critical path care plans. Journal of Psychosocial Nursing & Mental Health Services, 32 (7), 25-9.
Abstract: 1. Mental Health providers are under increasing pressure to provide objective, individualized care that produces outcomes that may be measured against accepted clinical standards. 2. Clinicians may now track patient responses throughout a continuum of treatment in varying locations by using a customized critical path/treatment plan format. 3. Care delivery is documented by superimposing actual occurrences over desired ones on a critical pathway

103.    Woods, E. N. (1994). What does it mean for physical therapy? PT--Magazine of Physical Therapy, 2(6), 34-41.
Abstract: Your hospital administrators are starting to use terms like "cross training," "critical pathways," and "patient focused care" -- and the anxiety levels are running high. The restructuring of hospitals across America may lead to cost savings, greater efficiency, and increased patient satisfaction. But what does it mean for the health care disciplines within the hospitals? How will physical therapy be affected? Starting next month, PT will launch a five-part series of case studies that detail the experiences of hospital physical therapy departments and how they made a successful transition to a new model of service delivery. But first, here's an overview of the topic

104.    Sperry, S. (1994). Opportunities and challenges: strategies for implementing multidisciplinary documentation forms. Aspens Advisor for Nurse Executives, 9(9), 1,3-4 special insert 2 p.

105.    Smith, K. G. (1994). Critical pathways.  Food Management, 29(6), 44.

106.    Sarkissian, S. (1994). Length of hospital stay and contributing variables in supratentorial craniotomy patients with brain tumour: a pre-care map study. Axone, 15(4), 86-9.
Abstract: The study included 70 patients admitted to Neurosurgical ICU (NICU) with the diagnosis of Supratentorial Craniotomy for Brain Tumour. These patients were followed throughout their hospitalization in NICU, to the ward and until discharge from hospital. The purposes of the study were (a) to indicated the NICU and floor length of stay (LOS) in this group of patients, prior to the use of care map and compare it to a developed care map, and (b) to identify the variables that contribute toe overall prolonged hospital LOS. The findings indicated that, prior to the use of care map, 68.8% of Supratentorial Craniotomy Patients with Brain Tumour had an ICU LOS of one day. However, only 38.6% of these patients were discharged from hospital within the care map indicated 5 day post ICU, floor LOS. The findings also showed that the overall hospital LOS, in 71.4% of the patients, was over 7 days, as indicated on the developed care cap. Several variables such as patient complications, consults, rehab/placement, patient falls and additional diagnostic tests contributed to the overall pronged hospital LOS. Thus, by monitoring these variables with the use of a care map, may produce measurements to evaluate cost effectiveness, and allow health care professionals to provide more effective and quality patient care

107.    Richards, K. F. (1994). Developments in total quality management in the United States: the Intermountain Health Care perspective. Quality in Health Care, 3(Suppl ), 20-24.
Abstract: In summary our purpose has been to evaluate quality in the following terms. Best process of care--narrowing the variation of care decisions, working towards the best method. Best clinical outcome--decreased morbidity ond mortality. Best patient satisfaction--both for clinical outcome and the process of care. Best value--best value at the lowest cost. At Intermountain Health Care we believe that the best way to achieve the best quality improvement in a health care system is to involve all of the participants--patients, providers, and systems--in employing the principles of total quality management. Patient involvement--in prevention; participating in best care process through education and utilisation; in evaluating functional status before, during, and after intervention; in satisfaction; in clinical outcome and follow up with providers. Provider involvement--in planning, implementing, analysing, and educating; in defining guidelines; in reassessing and defining guidelines; in reassessing and continually modifying the care map, always striving for "best care." System involvement--in providing structure and mechanisms, support staff, and information systems and being willing to focus on quality as a part of its mission. An American philosopher, George Santayana, once said: "What we call the contagious force of an idea is really the force of the people who have embraced it." It will be up to all of us collectively to become the force behind moving quality management principles into the forefront of patient care methodology and ensuring that quality remains as the guiding principle of health care delivery in the future.  (Abstract by: Author)

108.    Moss, M. T. (1994). Nursing tools: a global perspective... three tools form a triangular analytical instrument, outcomes management, case management and critical pathways. Nursing Management, 25(6), 64A-B.

109.    Meiches, R. K. (1994). Fairview's Clinical Pathway Project. Minnesota Medicine, 77(6), 9-11.

110.    Hyde, K., & Kiser, L. (1994). CHF pathways cuts annual pharmacy costs and per-case LOS. Hospital Case Management, 2(6), 97-100.

111.    Greiner, J. E. (1994). Microlevel documentation: relational database for critical path development. Seminars for Nurse Managers, 2(2), 72-8.
Abstract: There have been great strides in developing hospital information systems (HISs); however, there are few if any systems that are fully integrated to allow nursing documentation at microlevel data--that is, information about interventions between a nurse or other health care disciplines and the patient. It consists of the data used by a nurse in taking care of patients at the intervention level. This article suggests a process for developing a fully integrated HIS that will build a nursing minimum data set (NMDS) to aid in case management systems development, costing-out services, and nursing research. The goal of the system is to decrease the amount of paperwork, allowing the nurse to spend more time with the patient, and at the same time improving the quality of documentation and improving patient outcomes

112.    Base, P. (1994). Examples of critical paths for use in the emergency department [letter]. Journal of Emergency Nursing, 20(3), 174-5.

113.    Walsh, J. A. (1994). Commentary on Case management: development of a model [original article by Lynn-McHale DJ et al appears in CLIN NURSE SPEC 1993;7(6):299-307]. ONS Nursing Scan in Oncology, 3(3), 20.
Abstract: SYNOPSIS: The case managment model was developed in response to the rapid changes in health care in the 1990s. Managed care focuses on organizing health care in order to meet specific outcomes within a specific time period. Managed care is usually associated with acute care episodes but may also be used by outpatient services. The case manager who oversees managed care requires excellent clinical and communication skills. An advanced practice nurse, such as a clinical nurse specialist or a nurse practitioner, is appropriate for this role. A hospital or agency multidisciplinary planning committee develops, guides, and evaluates the implementation of this care delivery model. Critical pathways using nursing diagnosis structure patient outcomes for the case management plan. The case manager identifies and investigates any variance to the plan and uses the quality-assurance program for review. The case management system increases staff and patient satisfaction. It must be dynamic in order to meet the continually changing needs of patients and the demands of health care. [Original article accession number: 1994177139]

114.    Olson, L. L. (1994). Commentary on Patient-focused care... playing to win [original article by Clouten K et al appears in NURS MANAGE 1994;25(2):34-6]. Aone's Leadership Prospectives, 2(3), 23.
Abstract: Topic: The concept of patient-focused care is presented as a patient care delivery model that requires a complete redesign in the way hospitals are traditionally organized. Purpose: The discussion of the components of patient-focused care included the use of ancillary staff who are cross-trained in order to bring services closer to the patient. The management structure is flattened and the nursing staff assume empowered roles. Other components include use of work teams, critical pathways, and grouping similar patient populations together. Source: First implemented in a hospital in Florida, the patient-focused care model is coming to the forefront in many hospitals throughout the nation as a way to bring services closer to the patient as well as to control the rising costs of health care. Conclusions: It is very important to view the patient-focused model as a radically different way of organizing hospital services, or as a paradigm shift. The complete redesign of the hospital delivery system requires that nurse managers also make a paradigm shift. Redesigned organizations strive for increased interdisciplinary collaboration and decentralized services. [Original article accession number: 1994188958]

115.    Milne, C. T., & Pelletier, L. C. (1994). Enhancing staff skill. Developing critical pathways at a community hospital. Journal of Nursing Staff Development, 10(3), 160-2.
Abstract: Clinical pathways are an essential tool in implementing case management. The authors, in this article, describe how one institution developed and implemented critical pathways. The result was enhanced staff skill in physical assessment, patient/family teaching, and communication with physicians

116.    Miller, M. T. (1994). Commentary on The CNS as trauma case manager: a new frontier [original article by Daleiden AL appears in CLIN NURSE SPEC 1993;7(6):295-8]. ENA's Nursing Scan in Emergency Care, 4(3), 22.
Abstract: Trauma case management is a multidisciplinary approach to the care of the trauma patient. In this article, the role of trauma case manager (TCM) is fulfilled by the CNS in a Level II trauma center through the roles of expert practitioner, educator, consultant, researcher, and manager. As the author explains, traumatic injury care is difficult to standardize into structured critical pathways. By using a CNS TCM, trends can be identified and critical pathways developed that incorporate an interdiscipline team approach to trauma care. [Original article accession number: 1994177138]

117.    McCracken, S., Colburn, K., & Pastorik, L. (1994). Hospice care: mapping the message. American Journal of Hospice & Palliative Care, 11(3), 30-5.
Abstract: A study into the community image of Hospice of Central Iowa (HCI) was undertaken to guide the organization in making future decisions about its position in the health care market. Consumer perceptions are important if the hospice seeks steady growth in a market where potential consumers have an intense personal involvement with the service. Using a perceptual mapping technique, HCI was able to quantify and rank the importance of certain factors in influencing choice of a care setting for a terminally-ill person. It also enabled HCI to measure whether the message it had been promoting in its public relations activities was being received by consumers. The mapping techniques allowed HCI to compare how it is perceived with how other competitive health care providers, namely, hospitals, nursing homes and home health agencies are perceived by these same consumers. Finally, the technique offers information to the hospice as to the type of image development it must pursue to appeal to potential consumers making choices about care for terminally-ill people

118.    James, C. (1994). Commentary on A suburban community emergency department's adaptation of case management [original article by Pins C et al appears in J EMERG NURS 1993:19(6),503-9]. ENA's Nursing Scan in Emergency Care, 4(3), 13.
Abstract: Although many hospitals currently practice case management it is not typically practiced in EDs. This particular ED developed their version of critical pathways -- anticipated recovery pathways (ARPs) -- to standardize documentation and care. Nine of the high-volume, high-acuity, and potentially problematic diagnosis groups (approximately 65% of the ED patient load) were selected for ARP development. The process initially increased paperwork and the new forms required revisions to achieve staff compliance. Expected benefits from the system include improved medical and nursing collaboration; decreased duplication of services; and improved documentation for patient care, evaluation, and orientation. With the asthma ARP, patients experienced shorter lengths of stay and had less need for radiographs and laboratory studies. [Original article NLM unique identifier: 1994191208]

119.    Gallagher, C. (1994). Applying quality improvement tools to quality planning: pediatric femur fracture clinical path development. Journal for Healthcare Quality, 16(3), 6-14.
Abstract: Quality improvement tools that integrate clinical and financial data provide a statistical basis for quality planning and cost containment. Clinical path development results in an operational guideline for optimizing quality and efficiency. Implementation provides the means for delivering value. This article describes a step-by-step process in which quality improvement tools were used to develop a pediatric femur fracture clinical path at the author's hospital.  (Abstract by: Author)

120.    Luquire, R. (1994). Focusing on outcomes. RN, 57(5), 57-60.
Abstract: Outcomes management will be crucial to effective health care reform. Nurses at this hospital have a system up and running that can serve as a model for others who want to get the machinery moving before government and health insurers mandate it.  (5 ref)

121.    Evers, C., Odom, S., Latulip-Gardner, J., & Paul, S. (1994). Developing a critical pathway for orientation. American Journal of Critical Care, 3(3), 217-23.
Abstract: A direct correlation exists between job satisfaction and employee retention with an organized and compassionate orientation process for new employees on a nursing unit. It is generally recognized that preceptorship/mentoring is the most desirable orientation modality; however, situations occasionally require orientees to work with several preceptors with varying levels of proficiency. A program based upon a framework designated "critical pathway" was established in a coronary care unit and a cardiac progressive care unit to organize orientation information into weekly segments, with each week's content building upon the previous week's information. Because the critical pathway clearly delineates the orientation content, all necessary information is imparted to the orientee in an organized fashion without omitting pertinent details. Problems with orientation are documented as variances on the critical pathway, and are discussed between the preceptor and orientee during weekly evaluation sessions. This article reports the procedure for developing a critical pathway for orientation using the critical pathway concept, which is adapted from the nursing case management practice model

122.    Bero, A. F., & Gillmore, V. L. (1994). Small hospital makes best use of existing staff. Hospital Case Management, 2(5), 75-78.

123.    Berkey, T. (1994). Benchmarking in health care: turning challenges into success. Joint Commission Journal on Quality Improvement, 20(5), 277-84.
Abstract: BACKGROUND: Since 1990, more than 120 partner hospitals have participated in 15 projects using a collaborative benchmarking approach developed by SunHealth Alliance. EXAMPLE: Medical records project. Twenty hospitals focused on activities that could reduce accounts receivable days in medical records for Medicare inpatients. Thirty-five key practices, as identified by correspondence and site visits for four benchmark hospitals, were reviewed with all 20 hospitals. EXAMPLE: Pneumonia project. Four hospitals focused on reducing the length of stay and mortality rates for pneumonia (DRG [diagnosis-related group] 89) patients. Each hospital formed internal task forces, who reviewed comparative data, analyzed their hospitals' internal care processes, determined opportunities for improvement, and chose best practices for implementation-including standardizing the sputum-collection process and developing a clinical path. Meeting the challenge. Hospitals should strive for innovation, seek new goals of excellence, and share their successes with other hospitals

124.    Barnes, R. V., Lawton, L., & Briggs, D. (1994). Clinical benchmarking improves clinical paths: experience with coronary artery bypass grafting. Joint Commission Journal on Quality Improvement, 20(5), 267-76.
Abstract: BACKGROUND: Clinical paths and clinical benchmarking are consistent with, and readily adaptable to, any health care organization that espouses the principles of continuous quality improvement. CLINICAL PATHWAY: In its initial clinical path project, Borgess Medical Center analyzed and streamlined the processes of caring for a coronary artery bypass graft (CABG) patient. Team discussions were driven by comparative data, specialty guidelines, peer review organization guidelines, patient financial statements, patient records, and the applicable literature. One year after the CABG clinical paths were implemented, average total charges to the patient dropped from $35,700 to $32,700. Average length of stay also dropped, from 11.1 to 9.7 days. The mortality rate held stable at 2.7%. CLINICAL BENCHMARKING: Recognizing the opportunity to further improve its CABG clinical path, Borgess participated in MediQual's CABG benchmarking project. The team followed MediQual's five phases of clinical benchmarking: focus and opportunity assessment, outcome analysis and comparison, clinical process documentation, benchmark process comparison, and action planning, implementation, and monitoring. Using benchmark data provided by MediQual, the CABG benchmark team focused on the high-risk population and identified further opportunities for streamlining the CABG clinical pathway. Several areas for improvement were identified by comparing Borgess's practices to the benchmark hospitals. CONCLUSION: Developing a clinical path before beginning to benchmark "forced" Borgess Medical Center to develop a clear understanding of its own processes. This allowed the benchmark team to easily identify variances between its CABG processes and those of the benchmark hospitals and to select which variations the hospital should adopt

125.    Fling, S. P., Arp, B., & Pious, D. (1994). HLA-DMA and -DMB genes are both required for MHC class II/peptide complex formation in antigen-presenting cells. Nature, 368(6471), 554-8.
Abstract: Major histocompatibility complex (MHC) class II molecules are highly polymorphic cell-surface glycoproteins that present antigenic peptides to CD4+ T lymphocytes. The normal assembly of class II molecules with cognate peptides for antigen presentation requires an accessory function provided by a gene mapping to the class II region of the HLA complex. The isolation of somatic cell mutants of antigen-presenting cells (APC) has shown that at least one gene which maps between HLA-DP and HLA-DQ, provisionally designated c2p-1 (ref. 3), mediates this process. Here we describe a unique new mutant 2.2.93, which manifests defective formation of class II/peptide complexes like that described in c2p-1 mutants. We show that (1) mutant 2.2.93 contains a mutation in HLA-DMA, and a representative c2p-1 mutant, 9.5.3, contains a mutation in HLA-DMB; and (2) transfection and expression of DMA complementary DNA in 2.2.93, and DMB cDNA in 9.5.3, reverses their mutant phenotypes. These results show that HLA-DMA and -DMB, genes of previously unknown function mapping between HLA-DP and HLA-DQ, are required for the normal assembly of peptides with MHC class II molecules. They suggest that HLA-DMA and -DMB encode subunits of a functional heterodimer which is critical in the pathway of class II antigen presentation

126.    Rudisill, P. T., Phillips, M., & Payne, C. M. (1994). Clinical paths for cardiac surgery patients: a multidisciplinary approach to quality improvement outcomes. Journal of Nursing Care Quality, 8(3), 27-33.
Abstract: Implementation of clinical paths has resulted in a successful multidisciplinary approach for monitoring quality improvement outcomes in a select group of cardiovascular patients. This article defines clinical paths and explains their development, implementation, and evaluation. It also discusses how variances (which are defined as discrepancies between expected and actual events) were identified and how this information led to actions to improve patient outcomes. The roles of each health care professional are discussed in relation to clinical paths, and positive outcomes for the nurse, other health care professionals, and the institution are presented

127.    McLean, M., Kelly, K., Conroy, V., & Fuller, S. (1994). CRITICAL PATH NETWORK. Integrated clinical pathway documentation: it works! Hospital Case Management, 2(4), 61-4.

128.    Chu, S., & Thom, J. (1994). Information technology as a proactive strategic weapon in healthcare. Journal of Nursing Administration, 24(4), 5-7.

129.    Lord, J. T. (1994). Architects of care; how we built support for clinical pathways [interview by Kevin Lumsdon]. Hospitals & Health Networks, 68(6), 20-1.
Abstract: When executives at Anne Arundel Medical Center committed the organization to a strategic focus on measuring and improving performance, they didn't simply tinker with the margins of clinical activity; they dispatched teams of clinicians and patients to redesign care. In developing clinical pathways, the teams achieved dramatic reductions in length of stay--and increased satisfaction all around. Jonathan T. Lord, M.D., previously senior vice president for medical staff affairs at the Annapolis, MD, facility, spoke recently with senior editor Kevin Lumsdon about the intricacies of the initiative--and how he's taking that experience into his current position as executive vice president for clinical services at the SunHealth Alliance, Charlotte, NC

130.    Healey, K. M., Loukota, S. S., Sears, T. D., Miles, R. R., & Galbraith, T. A. (1994). Innovation and dedication. One institution finds critical paths are only part of the quality/cost solution. Hospitals & Health Networks, 68(6), 68, 70, 72-74.

131.    Rosenstein, A. H. (1994). Cost-effective health care: tools for improvement. Health Care Management Review, 19(2), 53-61.

132.    McMahon, L. F. Jr, Eward, A. M., Bernard, A. M., Hayward, R. A., Billi, J. E., Rosevear, J. S., & Southwell, D. (1994). The integrated inpatient management model's clinical management information system. Hospital & Health Services Administration, 39(1), 81-92.
Abstract: The rising cost of health care has increased the call for cost control. The pressing need to control cost, coupled with the increase in managed care and prospective payment, has placed new urgency on administrators and clinicians to work collaboratively in providing efficient and effective care. We have developed the Integrated Inpatient Management Model (IIMM) to assist in this collaborative effort. We describe the IIMM's clinical information system that provides decision support to both administrators and clinicians. This clinical information system is the information backbone for the development and monitoring of practice guidelines or critical pathways. An integrated information system of this type is essential if hospitals are to prosper during the next decade.  (Abstract by: Author)

133.    Olson, L. L. (1994). Commentary on Patient-focused care: is it for your hospital? [original article by Townsend M appears in NURS MANAGE 1993;24(9):74-80]. Aone's Leadership Prospectives, 2(2), 5.
Abstract: Topic: The principles, assumptions, and cost considerations associated with patient-focused care (PFC). Many hospitals are implementing this popular model to place the patient at the center of care, thereby increasing patient and staff satisfaction and decreasing costs. Purpose: It is important to plan for the redesign inherent in PFC and also to include key stakeholders from all levels. Each PFC assumption must undergo critical examination to determine whether it is right for the hospital. Source: The identified components of PFC include the principles and assumptions of aggregating patients by similarities, redeploying services, cross-training multiskilled workers, simplifying systems and documentation, and redesigning facilities. The use of critical pathways to standardize patient care planning and total quality management to manage and evaluate quality, shared governance, and role clarification is often associated with a PFC model. Conclusions: The author identified that the largest costs of the PFC model relate to employee training and facilities redesign. An incremental approach and testing of each precept saves committing full resources. Clarity of organizational vision is essential for success

134.    McGregor, L. A. (1994). Short, shorter, shortest: improving the hospital stay for mothers and newborns. MCN, American Journal of Maternal Child Nursing, 19(2), 91-6.

135.    Hirtzel-Trexler, B. J. (1994). Commentary on Critical pathway patient outcomes: the missing standard [original article by Woodyard L et al appears in J NURS CARE Q 1993;8(1):51-7]. Aone's Leadership Prospectives, 2(2), 21.
Abstract: Topic: Critical pathways are quality standards, not simply tools to manage care. Purpose: To develop outcome standards for diagnostic groups in order to expand critical pathways to include specific outcomes. Sources: A review of case-management and quality-management literature to develop outcome standards for critical pathways in their institution. Conclusions: The multidisciplinary critical pathway is a highly successful communication tool as well as a mechanism for managing the process of patient care. Deviations from accomplishment of the specified tasks were analyzed quantitatively, but there was no way to identify quality outcomes. Desired patient outcomes were assumed to be understood by the nursing staff, yet the authors did not find consistency among practitioners' understanding of the outcomes. Additionally, clinical standards were not functioning as a framework for practice

136.    Borkowski, V. (1994). Implementation of a managed care model in an acute care setting. Journal for Healthcare Quality: Promoting Excellence in Healthcare, 16(2), 25-7, 30.

137.    Taylor, P., Peterson, S., Crawford, P., & Williams, A. (1994). CRITICAL PATH NETWORK. Hospital reduces length of stay with adult asthma critical path. Hospital Case Management, 2(3), 43-6.

138.    Romijn, C. A., Luttik, R., & Canton, J. H. (1994). Presentation of a general algorithm to include effect assessment on secondary poisoning in the derivation of environmental quality criteria. 2. Terrestrial food chains. Ecotoxicology & Environmental Safety, 27(2), 107-27.
Abstract: In a previous study a simple algorithm was presented for effect assessment on secondary poisoning of birds and mammals. This algorithm (MPC = NOECfish-eater/BCFfish) was drawn up by analyzing a two-step aquatic food chain (water-fish-bird/mammal). The algorithm was used to test whether quality criteria set for surface water, based on effect assessment for aquatic organisms, constitute a "safe" level for secondary poisoning. The present study analyzes whether this algorithm can equally well be used for effect assessment in a terrestrial food chain. The pathway soil-earthworm-bird/mammal was used as an example for a terrestrial food chain. Literature data of six selected compounds (lindane, dieldrin, DDT, PCP, cadmium, and mercury) on both bioconcentration factors for earthworms and toxicity data for birds and mammals were studied. Important differences were found between BCFs for this terrestrial pathway and BCFs for the aquatic pathway analyzed in the previous study. It was found that BCFs for earthworms were more dependent on soil-related properties than on compound-specific properties. Hence, it was concluded that the algorithm MPC = NOECworm-eater/BCFworm can be used only for effect assessment on terrestrial food chain in defined situations. By calculating maximum permissible concentrations for secondary poisoning (MPCsp) for a standard soil situation and comparing these to MPCs for soil organisms, it was concluded that secondary poisoning could be a critical pathway for cadmium and methyl mercury. For methyl mercury secondary poisoning in an aquatic food chain was also a critical pathway. Secondary poisoning of fish-eating birds and mammals is not likely to occur for cadmium at concentrations in water below the MPC calculated for aquatic organisms

139.    Morrish, S. L. (1994). Pediatric cerebellar medulloblastoma and extraneural metastases: a case study. AXON, 15(3), 54-7.

140.    Ebert, J. (1994). Setting the course for critical pathways. Continuing Care, 13(2), 24-5-28.

141.    Ritz, D. (1994). Getting on the critical path. Rehab Management: The Interdisciplinary Journal of Rehabilitation, 7(2), 113-114.
Abstract: One hospital's experience with pathways for total joint replacement yields benefits in program outcomes and cost-effectiveness

142.    Vitello, J. (1994). Time to choose your own critical path. Critical Care Nurse, 14(1), 142.

143.    Rohl, B. J., Meyer, L. C., & Lung, C. L. (1994). Asthma care map for decision making. Medical Interface, 7(2), 107-10.
Abstract: In the second part of a three-part series on patient-centered asthma care, the authors describe the eight critical elements of multidisciplinary care management for patients with moderate to severe asthma.  (Abstract by: Author)

144.    Rasmussen, N., & Gengler, T. (1994). Clinical pathways of care: the route to better communication. Nursing, 24(2), 47-9.

145.    Metzler, S. (1994). Using detailed billing data to develop critical paths. QRC Advisor, 10(4), 4-6.
Abstract: In summary, billing data can provide valuable information that is key to critical path development. The data can easily be retrieved and analyzed without time-consuming medical record review and will help focus development efforts on treatment patterns that can have the greatest impact on patient care. This impact will vary from hospital to hospital depending on the objectives of the critical path development and educate developers in the process.  (Abstract by: Author)

146.    Gooldy, J., & Duncan, B. (1994). Home care's role in clinical pathways. Journal of Home Health Care Practice, 6(2), 63-9.
Abstract: In 1989, the leadership of Anne Arundel Medical Center made a commitment to refocus its energies on measuring and improving performance. The continuous performance improvement plan included several key initiatives, one of which was the development of clinical pathways. Clinical pathways have existed in health care organizations for several years; unfortunately most efforts have focused on inpatient management with emphasis on physician and nurse activities. The clinical pathways in Anne Arundel Medical Center begin with the patient at the point of entry into the health care system and end at the point of optimal wellness. The Home Health Agency is currently integrated into 13 clinical pathways. The clinical pathway for total hip replacement is discussed to demonstrate home care's unique role. Outcomes for the initial 2 years of the pathway demonstrate positive clinical outcomes, positive perception of services, and cost-effective use of resources.  (1 ref)

147.    Brandt, M. (1994). Clinical practice guidelines and critical paths--roadmaps to quality, cost-effective care (Part II).  Journal of Ahima, 65(2), 54-7; quiz 58-9.

148.    Thompson, D. G. (1994). Critical pathways in the intensive care & intermediate care nurseries. MCN, American Journal of Maternal Child Nursing, 19(1), 29-32.

149.    Pais, M. B. (1994). An interview with Mary Beth Pais [interview by Connie R Curran]. Nursing Economics, 12(1), 5-9.
Abstract: Mary Beth Pais, MNEd, RN, ONC, the recipient of the 1993 Nursing Economic$ Excellence Award, is clinical nurse manager, University of Pittsburgh Medical Center, Montefiore University Hospital, Pittsburgh, PA. In this interview she discusses the challenges and lessons learned from developing a work redesign model, critical paths, and the implementation of a pre-operative patient assessment and education program

150.    Eckhouse-Ekeberg, D. R. (1994). Promoting a positive attitude in pediatric patients undergoing limb lengthening. Orthopaedic Nursing, 13(1), 41-9.
Abstract: Pediatric patients undergoing external fixation for limb lengthening have to adjust to having the devices on their extremities for many months. This treatment requires a great deal of time and commitment from both the child and family in managing the device. Our hospital interdisciplinary limb lengthening (LLD) team discovered that having the patient and family involved is the key to getting children to resume their home routines. The team also discovered that since children's locus of control develops as they mature, the LLD process could give these patients a greater opportunity to develop an internal ("I'm in charge") rather than an external ("powerful others") locus of control. Therefore, it is essential to include the patient and family as part of the interdisciplinary team so that a positive psychologic outcome to limb lengthening can be attained.  (26 ref)

151.    Curran, C. R. (1994). An interview with Mary Beth Pais... the recipient of the 1993 Nursing Economic$ Excellence Award.  Nursing Economics, 12(1), 5-9.
Abstract: Mary Beth Pais, MNEd, RN, ONC, the recipient of the 1993 Nursing Economic$ Excellence Award, is clinical nurse manager, University of Pittsburgh Medical Center, Montefiore University Hospital, Pittsburgh, PA. In this interview she discusses the challenges and lessons learned from developing a work redesign model, critical paths, and the implementation of a pre-operative patient assessment and education program

152.    Zander, K. (1994). Case management update. Seminars in Perioperative Nursing, 3(1), 55-8.
Abstract: Karen Zander, a member of the original research team at the New England Medical Center Hospital that created the first hospital case management model and critical pathways, outlines recent developments in education, automation, and research that she says point to an increasing interest in these two health care delivery strategies

153.    Royer, K. (1994). A case management experience with cholecystectomies. Seminars in Perioperative Nursing, 3(1), 3-12.
Abstract: Case Management can be used in developing plans to evaluate the care given to patients undergoing operative cholecystectomies. Although many cholecystectomies are now performed by laparoscope, some patients fail to meet the criteria for laparoscopic cholecystectomy and, therefore, require the open approach. This project was undertaken to scrutinize the time and activities of care for patients undergoing cholecystectomies to provide a baseline of information for the comparison of open cholecystectomy with laparoscopic cholecystectomy. Copyright (c) 1994 by W.B. Saunders Company  (11 ref)

154.    Rowland, J. O. (1994). Case management and critical paths in the PACU. Breathline, 14(1), 14, 18.

155.    Moss, M. T. (1994). Practical implementation of outcomes oriented case management. Seminars in Perioperative Nursing, 3(1), 40-5.
Abstract: With the redefinition of health care in the United States, more and more nurses are being drawn into the decision-making arena. They are actively involved in the allocation of human and material resources. Critical paths are being developed to help monitor efficient, cost-effective, and quality patient care. As a result of these critical paths, nurses are evaluating the courses of patient care in terms of outcomes

156.    Madrid, C. (1994). Orthopedic case management in a collaborative practice setting. Seminars in Perioperative Nursing, 3(1), 13-5.
Abstract: An orthopedic practice that consists mainly of total joint replacements is an ideal setting for a case manager. While fixed reimbursement demands that care be cost-effective, an older patient population presents with more complex health problems. Key factors towards achieving successful patient outcomes are thorough preoperative assessment, patient and family education, and the development of critical pathways

157.    Kifer, D. J. (1994). Case management of needle localized breast biopsy patients. Seminars in Perioperative Nursing, 3(1), 46-54.
Abstract: This article describes the development of a pilot project for case management (CM) for patients undergoing needle localization breast biopsy within a large military medical center. A case management plan, timelines, and critical path were developed. Four patients were followed through the entire process of needle localization breast biopsy from preadmission to discharge using the pathway. Variances from the critical path are discussed. Quality, efficiency, and efficacy of care given to this patient population at this facility can be improved through the use of CM

158.    Geeze, M. A. (1994). Pediatric outpatient upper endoscopy: perioperative case management. Seminars in Perioperative Nursing, 3(1), 27-39.
Abstract: A case management (CM) project was initiated for pediatric patients undergoing an outpatient endoscopy procedure. Health care professionals must meet the physical and psychological needs of the entire family unit when working with children. Meeting the needs of the child is accomplished more easily when the parents/guardians understand the process and are informed. Using a critical pathway and CM plan helps the nurse to accomplish this task. By using all members of the health care team, CM systematically moves the child and his/her parents/guardians through the hospital experience in an anticipated manner that is caring, efficient, and cost-effective

159.    Chase, C. R. (1994). Development of a case management plan for aortoiliac bypass graft surgery patients. Seminars in Perioperative Nursing, 3(1), 16-21.
Abstract: Case management can reduce health care costs of the aortoiliac bypass graft surgery patient by eliminating unnecessary services, preventing duplication of services, and preventing costly readmissions in high-risk patients. This can be achieved through use of a case management plan that incorporates critical pathways, perioperative clinical nurse specialists as nurse case managers, ad hoc group practices, and patient and family participation

160.    Brandt, M. (1994). Clinical practice guidelines and critical paths--roadmaps to quality, cost-effective care (Part I). Journal of Ahima, 65(1), 51-4; quiz 55-60.
Abstract: Clinical practice guidelines and critical paths have gained widespread acceptance in recent years. Part I of this article will examine clinical practice guidelines, or practice parameters, and their application to patient care. Part II (in the February issue of JAHIMA) will look at multi-disciplinary care plans known as critical paths and how they can incorporate clinical practice guidelines. Health information management professionals can play an important role in implementation and ongoing evaluation of these clinical tools.  (Abstract by: Author)

161.    Gruendemann, B. J. (1994). Critical pathways [editorial]. Asepsis, 16(4), 1.

162.    Spath, P. L. (1994). Clinical paths: tools for outcomes management. Chicago, IL: American Hospital Pub.

163.    Joseph, E. D., & Crowhurst, E. (1994). Critical pathways in geriatric care. Hinsdale, IL: Care Educ Group.

164.    Pins, C. L., & Swanson, M. E. (1993). A suburban community emergency department's adaptation of case management. Journal of Emergency Nursing, 19(6), 503-9.
Abstract: Nursing and management staff at Unity Hospital's emergency department in Fridley, Minnesota, have successfully translated the principles of case management into a nursing documentation form that defines expectations of care within specific time frames.  (8 bib)

165.    Odderson, I. R., & McKenna, B. S. (1993). A model for management of patients with stroke during the acute phase. Outcome and economic implications. Stroke, 24(12), 1823-7.
Abstract: BACKGROUND AND PURPOSE: The purpose of the study was to develop a clinical pathway for patients with nonhemorrhagic stroke during the acute hospital phase to improve the quality of care and reduce costs. METHODS: The pathway included standard admission orders and a swallow screen on day 1 of hospitalization. Physical therapy, occupational therapy, speech therapy, and social worker assessments were done on day 2. A physiatry consult was performed on day 3 if indicated, and by day 4 a discharge target date and disposition were addressed. RESULTS: Outcomes for 121 patients during the first year of pathway implementation are reported. The average length of stay on the acute service decreased from 10.9 days to 7.3 days (P < .05), reducing the charges per patient by 14.6%. Complications in the form of urinary tract infections and aspiration pneumonia rates decreased by 63.2% (P < .05) and 38.7%, respectively. CONCLUSIONS: We conclude that the implementation of a clinical pathway for patients with acute, nonhemorrhagic stroke resulted in a significant reduction in length of stay, charges, and complications while improving the quality of care

166.    Misinski, M., Thompson, G. K., Talley, J. A., Lucich, S., & Johnson, R. (1993). Model for trauma outcomes management in patients with multiple trauma. Critical Care Nursing Clinics of North America, 5(4), 741-55.
Abstract: Critically injured patients whith chest trauma generally sustain severe life-threatening injuries. Post-operative care tends to be complex, and all aspects of care from pre-hospital through rehabilitation must be coordinated and communicated to maximize patient outcomes. The Trauma Outcomes Management Model allows clinicians to assess, track, and analyze the relationship among interventions, outcomes, and the cost of care for each phase of the trauma care continuum. This article presents the design and utilization of trauma outcome guides in the Emergency and Critical Care departments.  (7 ref)

167.    McCoy, M. L. (1993). Additional suggestion for chest pain critical pathway [letter]. Journal of Emergency Nursing, 19(6), 479.

168.    Lumsdon, K. (1993). Rule 1 on critical paths: proceed with caution. Hospitals & Health Networks, 67(22), 56.

169.    Schmele, J. A. (1993). Commentary on The critical path method alone does nothing to improve performance [original article by Luttman R appears in QUAL REV BULL 1993;19(5):142-3]. Aone's Leadership Prospectives, 1(1), 19.
Abstract: Topic: The author presents a timely issue about the relationship, or lack of relationship, between the Critical Path Method (CPM) and actual performance improvement. Scope: There is a need to reexamine the intended purpose of CPM, use quality-improvement tools, and focus on opportunities for improvement. Source: This short succinct letter to the editor was written in response to a previously published article (January 1993, p. 8). Conclusion: The author implied that CPM is directed toward automating coordination of activities that are essential for expedient movement of the patient through the system rather than the pursuit of quality, which is often presumed. [Original article accession number: 1993173911]

170.    Rogers, A., Batterson, J., & Shurak, E. (1993). User-friendly forms for mother-baby nursing... a documentation system designed by nurses guides care and saves time. MCN, American Journal of Maternal Child Nursing, 18(6), 297-301.
Abstract: A documentation system designed by nurses guides care and saves time.  (6 bib)

171.    Porter, A. L. (1993). Commentary on Case management a must to survive managed care [original article by Barrett M in COMP HEALTHC 1993;14(6):22-5]. Aone's Leadership Prospectives, 1(1), 11.
Abstract: Topic: Effective case management requires efficient access to clinical and financial patient information. Scope: The article described a model for case-management information requirements across the continuum of care from preadmission screening to outpatient services. Source: A summary of the administrative, clinical, and financial data elements needed for case management as well as the suggested reporting mechanisms are included. Conclusion: The author supported ready access to clinical and financial information. The automation of critical paths is essential to case management. Physicians could use the pathway outline for ordering and performance variance reporting, which involves comparing the assigned protocol to actual service

172.    Moss, M. T., & O'Connor, S. (1993). Outcomes management in perioperative services. Nursing Economics, 11(6), 364-9.
Abstract: Unit-based outcomes management addresses DRG-specific patient populations, making established services more economically efficient within critically monitored populations. Perioperative outcomes management balances quality of care and costs.  (11 ref 18 bib)

173.    Lynn, P. (1993). UWMC's new "coordinated care" program. Washington Nurse, 23(6), 24.

174.    Weilitz, P. B., & Potter, P. A. (1993). A managed care system: financial and clinical evaluation. Journal of Nursing Administration, 23(11), 51-7.
Abstract: The ever-changing healthcare environment requires that nurse executives explore alternative ways to deliver quality patient care, manage resources, and reduce length of stay. Care paths provide one such alternative, incorporating multidisciplinary care planning, discharge planning, and documentation in a patient-centered design. This model includes a clinical and financial system for evaluating the impact of the care path on resource utilization, length of stay, and patient outcomes.  (8 ref)

175.    Vollmer, C. (1993). Librarians join the clinical pathways team. National Network, 18(2), 6-11.

176.    Vogel, D. P. (1993). Patient-focused care [see comments]. [Review] [31 refs]. American Journal of Hospital Pharmacy, 50(11), 2321-9.
Notes: Comment in: Am J Hosp Pharm 1993 Nov;50(11):2317
Abstract: The trend away from a departmental focus and toward "patient-focused" care in hospitals is described; advantages of and barriers to such a change and its effects on pharmacy are discussed. Patient-focused care is characterized by decentralization of services, cross-training of personnel from different departments to provide basic care, interdisciplinary collaboration, various degrees of organizational restructuring, use of "clinical pathways"--recommended components of care for patients with a particular diagnosis, simplification and redesign of work to eliminate steps and save time (e.g., providing care according to predetermined protocols and charting only exceptions to the protocol), and increased involvement of patients in their own care. Its objectives are to use nonclinical and clinical staff more effectively and to improve patients' perceptions of the quality of care and staff members' job satisfaction. It is unrealistic to expect quick reductions in hospital costs through patient-focused care, and workers will worry about job security if an institution overemphasizes this aspect. A 1993 survey of 311 hospitals found that almost half had or planned to have patient-focused care projects. Adoption of patient-focused care projects may be slowed by workers' fear of new responsibilities and new reporting relationships. However, not all patient-focused care models involve radical organizational changes, and reorganizations can be such that pharmacy staff members are still connected to the pharmacy department even if they are supervised by a nonpharmacist. In some institutions patient-focused care projects have given pharmacy its first opportunity for decentralization.(ABSTRACT TRUNCATED AT 250 WORDS) [References: 31]

177.    Sona, C. (1993). The Clinical Advancement Model: filling in the gaps... gap in clinical knowledge between nurse managers/administrators and bedside clinicians. American Journal of Nursing, (Suppl), 52-9.
Abstract: No one nursing care model can meet all needs, but this one offers autonomy, expert care, and cost effectiveness.  (16 ref)

178.    Roche, J., & Lawrence, D. (1993). Developing a critical path for clinical paths. QRC Advisor, 10(1), 10-2.

179.    Paton, R. (1993). Fulfilling the commitment to improve patient care? Assessment of the effect of the Patient's Charter in a community hospital. Professional Nurse, 9(2), 130, 132,134.

180.   Lynn-McHale, D. J., Fitzpatrick, E. R., & Shaffer, R. B. (1993). Case management: development of a model. Clinical Nurse Specialist, 7(6), 299-307.
Abstract: Case management is the health care delivery model for the 1990s, answering the demands for provision of high quality care in a cost-effective manner. The CNS will play a pivotal role in the planning, development, implementation, and evaluation of a case management model. This article discusses practical aspects to consider when developing a case management model that meets the needs of a specific institution.  (32 ref)

181.    Campbell, P. A., & Runner-Heidt, C. M. (1993). A collaborative approach to home OKT3 infusion therapy. Journal of Nursing Administration, 23(11), 63-6.
Abstract: Hospitalization of patients who have undergone renal transplantation is often extended because of the need to complete complex antirejection infusion therapy. Because of the costs associated with prolonged hospitalization, medical professionals who provide care to these patients are developing programs that will facilitate attainment of quality care in the outpatient setting. The authors describe the effective implementation of a home Muromonab-CD3 (OKT3) intravenous administration program among renal transplant recipients based on thorough planning and close collaboration between the transplant service and home care staff.  (5 ref)

182.    Lumsdon, K., & Hagland, M. (1993). Mapping care. Hospitals & Health Networks, 67(20), 34-40.
Abstract: Managing clinical quality and assessing the efficacy of clinical operations are key objectives for all health care providers--but pressure is growing to do more with fewer resources. As a result, many innovators are turning to critical paths as a tool that can help them achieve those goals. Indeed, a new survey by Hospitals & Health Networks and Medicus Systems Corp. finds critical paths are taking hold in health care organizations in a big way. Of those hospital executives surveyed, 57 percent say they have a critical paths program. But the survey also uncovered a slew of names for the tools being used, and experts agree there are wide disparities in innovators' motivations, methods and achievements

183.    Woodyard, L. W., & Sheetz, J. E. (1993). Critical pathway patient outcomes: the missing standard. Journal of Nursing Care Quality, 8(1), 51-7.

184.    Taylor, K. S. (1993). Supply meets demand: hospital to tie critical paths, purchasing. Materials Management in Health Care, 2(10), 16.

185.    Griffin, J. F., & Buchan, G. S. (1993). Vaccination against tuberculosis: is BCG more sinned against than sinner?. [Review] [66 refs]. Immunology & Cell Biology, 71 ( Pt 5), 431-42.
Abstract: While extensive experimental studies of tuberculosis (Tb) have provided the foundation data for the discovery of cell-mediated immunity, there remains much to be disclosed about the critical pathways of immunity involved in this infectious process and the factors necessary to produce protective immunity. Studies on the aetiology and pathology of this disease have failed to elucidate the mechanisms of protective immunity. Although Tb research has been neglected for the past 30 years, the re-emergence of Tb worldwide as a significant zoonotic disease has re-focused research in this area. Scientific solutions for the control of Tb in man or domestic animals have not been found using empirical methods. Composite studies involving animal models of experimental infection will be necessary to critically evaluate vaccine efficacy and eludiate the basic immunological mechanisms involved in both disease and immunity. Available data which suggest that disease-related hypersensitivity and immunity are dissociable highlight the prospect that immunity to infection may be induced without compromising the continued need for ongoing systems of immunodiagnosis to exclude disease. In populations with a high prevalence of disease it is likely that a combination of immunodiagnosis, chemotherapy and immunoprophylaxis will be required to eradicate the disease. [References: 66]

186.    Flynn, A. M., & Kilgallen, M. E. (1993). Case management: a multidisciplinary approach to the evaluation of cost and quality standards. Journal of Nursing Care Quality, 8(1), 58-66.

187.    Tidwell, S. L. (1993). A graphic tool for tracking variance & comorbidities in cardiac surgery case management. Progress in Cardiovascular Nursing, 8(2), 6-19.
Abstract: Nursing case management has been documented as one solution to the balance of cost and quality issues in healthcare. A current focus in healthcare is continuous quality improvement (CQI). CQI methods are focused on outcome measurements. Outcome research is a recent development in case management. Tracking variance, evaluating cost reduction and patient effectiveness, and determining types of patients at risk for negative variance are current case management research demands. Tracking patient comorbidities would allow for additional subset "tailoring" of existing critical pathways for specific comorbidities. Little research has been done on these issues. Few systems exist that track both variance and comorbidities. This article presents a graphic, simple, multidisciplinary tracking system that includes comorbidities and allows for individual and group patient variance analysis

188.    Clements, F., & Love, K. (1993). Responsive restructuring: decision support for coordinated -- care financial and clinical integration... part 2. New Definition, 8(4), 1-4.

189.    Martich, D. (1993). The role of the nurse educator in the development of critical pathways. Journal of Nursing Staff Development, 9(5), 227-9.
Abstract: This article focuses on the role of the nurse educator in developing critical pathways. It serves as a guide for the nurse educator by defining how critical pathways support managed care, identifying the goals of critical pathway education, and reviewing the importance of organizational commitment to the critical pathways before their use. The nurse educator serves as instructor, facilitator, and consultant in critical pathway development

190.    Wadas, T. M. (1993). Case management and caring behavior. Nursing Management, 24(9), 40-2, 44-46.

191.    Mahn, V. A. (1993). Clinical nurse case management: a service line approach. Nursing Management, 24(9), 48-50.

192.    Goode, C. J., & Blegen, M. A. (1993). Developing a CareMap for patients with a cesarean birth: a multidisciplinary process. Journal of Perinatal & Neonatal Nursing, 7(2), 40-9.

193.    Smith-Rooker, J. L., Garrett, A., & Hodges, L. C. (1993). Case management of the patient with pituitary tumor. MEDSURG Nursing, 2(4), 265-74.
Abstract: Patients with pituitary tumors present multiple challenges to the medical-surgical case manager. Implementing a defined critical pathway for the patient with transphenoidal surgery can result in cost-effective care, fewer complications, and greater patient and family satisfaction.  (16 ref)

194.    Romijn, C. A., Luttik, R., van de Meent, D., Slooff, W., & Canton, J. H. (1993). Presentation of a general algorithm to include effect assessment on secondary poisoning in the derivation of environmental quality criteria. Part 1. Aquatic food chains. Ecotoxicology & Environmental Safety, 26(1), 61-85.
Abstract: Effect assessment on secondary poisoning can be an asset to effect assessments on direct poisoning in setting quality criteria for the environment. This study presents an algorithm for effect assessment on secondary poisoning. The water-fish-fish-eating bird or mammal pathway was analyzed as an example of a secondary poisoning pathway. Parameters used in this algorithm are the bioconcentration factor for fish (BCF) and the no-observed-effect concentration for the group of fish-eating birds and mammals (NOECfish-eater). For the derivation of reliable BCFs preference is given to the use of experimentally derived BCFs over QSAR estimates. NOECs for fish eaters are derived by extrapolating toxicity data on single species. Because data on fish-eating species are seldom available, toxicity data on all birds and mammalian species were used. The proposed algorithm (MAR = NOECfish-eater/BCF) was used to calculate MARS (maximum acceptable risk levels) for the compounds lindane, dieldrin, cadmium, mercury, PCB153, and PCB118. By subsequently, comparing these MARs to MARs derived by effect assessment for aquatic organisms, it was concluded that for methyl mercury and PCB153 secondary poisoning of fish-eating birds and mammals could be a critical pathway. For these compounds, effects on populations of fish-eating birds and mammals can occur at levels in surface water below the MAR calculated for aquatic ecosystems. Secondary poisoning of fish-eating birds and mammals is not likely to occur for cadmium at levels in water below the MAR calculated for aquatic ecosystems

195.    McGinty, H. M., Andreoni, V. M., & Quigley, M. A. (1993). Building a managed care approach. Nursing Management, 24(8), 34-5.

196.    Ziomek, R. (1993). Commentary on Case management with the nurse manager in the role of case manager in an interventional cardiology unit [original article by McElroy MJ et al] and Nurse clinician model of managed care [original article by Ahrens T] and Case management in the neonatal intensive care unit [original article by Gunderson L et al] and Implementing managed care in a pediatric setting [original article by Barnsteiner J et al] [articles appear in AACN CLIN ISSUES CRIT CARE NURS 1992;3(4):749-87]. AACN Nursing Scan in Critical Care, 3(4), 25.
Abstract: Managed care, frequently referred to as case management, uses specific care paths to guide the course of a patient's hospitalization. This series of articles describes multiple models that have been developed to deliver managed care in various critical care settings. The first article describes using the nurse manager as the case manager for an interventional cardiac care unit. The second article discusses the use of experienced staff nurses, or nurse clinicians, as case managers in a medical ICU. The third article reports the use of neonatal nurse practitioners as case managers in a neonatal ICU. The fourth article describes the role of the primary nurse in managed care as used in a pediatric hospital. These articles provide an overview of managed care and suggest guidelines for its development and implementation. Role development, position descriptions, performance standards, and clarification of roles for the various models are presented. The articles also address planning for managed care, including establishing time guidelines, developing critical paths, establishing an implementation plan, and evaluating patient outcomes. [Original article accession numbers: 1993154154, 1993154155, 1993154156, 1993154157, (forms, tables/charts, protocols]

197.    Kimball, L. (1993). Collaborative care: a quality improvement and cost reduction tool. Journal for Healthcare Quality, 15(4), 6-9.
Abstract: Collaborative care is a system of patient care delivery that focuses on the achievement of outcomes within effective and appropriate time frames and resources. It addresses the entire episode of illness, bridging all clinical settings in which the patient receives care. Through the collaborative efforts of multiple caregivers, a plan of medical care is mapped out that results in a clinical path. The clinical path can improve satisfaction levels for patients, nurses, rehabilitation staff, and physicians by establishing a method of reinforcement for everyone involved in efficient delivery of care.  (Abstract by: Author)

198.    Trinidad, E. A. (1993). Case management: a model of CNS practice. Clinical Nurse Specialist, 7(4), 221-3.
Abstract: Case management has been widely implemented as a new health care delivery model. The case manager has the pivotal role in the model. The CNS, having the clinical expertise, clinical judgment, and leadership, best suits the case manager's role. As a case manager, the CNS enacts the five role components: expert practitioner, educator, consultant, researcher, and manager. Case management, therefore, can be considered as a model of CNS advanced practice.  (12 ref)

199.    Mathias, J. M. (1993). Trying new tools: critical pathways, case management. Or-Manager, 9(7), 1-10-1.

200.    Hofmann, P. A. (1993). Critical path method: an important tool for coordinating clinical care. Joint Commission Journal on Quality Improvement, 19(7), 235-46.
Abstract: BACKGROUND: In May 1991 Mount Clemens General Hospital (MCGH) began investigating the critical path method (CPM) as a tool for extending total quality management in clinical areas. In its search for guidelines on how to develop a critical path program, it found that other hospitals used a variety of approaches. These included employing case managers or outside consultants to develop programs or implementing prepurchased paths. Because these approaches often are difficult to customize for a specific institution and because MCGH wanted to use an internal team, none of these options seemed appropriate. With no definitive guidelines to follow, MCGH developed and implemented its own CPM. METHODS: The developmental process was composed of activities in nine primary categories: literature search, steering group, targeting strategy, paperwork design, gaining consensus, pilot program, preliminary findings, refine program, and full implementation. RESULTS: A pilot was performed to assess if the CPM would be beneficial. Six months into the pilot a preliminary review of coronary artery bypass graft paths was conducted. There were 44 patients in the study group (35 men, 9 women). Twenty-four patients were cared for before the critical path form was available. Preliminary findings indicated a lower rate of complications in patients cared for with the critical path form. The data revealed a 5% complication rate with the critical path compared to a 16.6% rate for those whose care was not guided by the form. In addition, patients with the path on their clipboards had an overall shorter length of stay than patients without the path. It is important to remember that these early data are based on the six-month pilot; they are not considered a conclusive research finding. NEXT STEPS: The next step in the CPM process is to examine other diagnoses that might benefit from a critical path approach. A steering committee composed of representatives from hospital administration, nursing, medical staff, quality assurance and risk management, and total quality management will act as the approval body for investigating and sanctioning other paths for development. CONCLUSION: The primary lesson learned at MCGH is that the CPM is most effective in an environment of communication and commitment. This approach allows clinic and nonclinic staff to talk about how their work influences each other's. CPM provides all caregivers with a common language and encourages everyone to look at the whole patient and the entire care process. The key message of success is: Get a group of people together who are motivated and empowered to move this exciting tool of the future through the necessary steps

201.    Crummer, M. B., & Carter, V. (1993). Critical pathways--the pivotal tool. Journal of Cardiovascular Nursing, 7(4), 30-7.
Abstract: Case management is a nursing model that hospital administrators have implemented in an effort to reduce costs and improve quality. The pivotal tool that case management utilizes to standardize treatment plans, trend deviations from the standard, and document care is the critical pathway. Proper development, implementation, and utilization of critical pathways provide health care professionals and administrators with quantitative data on correlations between effective resource utilization and patient outcomes

202.    Chenger, P. L., & Erickson, S. (1993). The cost-effectiveness of coordinated care: how managed care and case management impact healthcare delivery. Tennessee Nurse, 56(2), 12-13.

203.    Richards, J. S., Sonda, L. P., Gaucher, E., Kocan, M. J., & Ross, D. A. (1993). Applying critical pathways to neurosurgery patients at the University of Michigan Medical Center. Quality Letter for Healthcare Leaders, 5(5), 8-10.
Abstract: Project Overview: In April 1990, The University of Michigan Hospitals began a major, multidisciplinary project to standardize care processes in order to increase efficiency and reduce costs while maintaining the quality of clinical care. A team of nurses began the project by developing critical pathways for two neurosurgery procedures--lumbar laminectomy and transphenoidal pituitary tumor resection. The pathways were reviewed by physicians and other staff from other disciplines and were implemented in January of 1991. Key Findings: Data from the first 14 months show a decrease in patients' average lengths of stay in both the intensive care unit (ICU) and routine care unit. Costs and variance data are being analyzed and further improvements to the pathways are being made. Eleven critical paths are now being used for neurosurgery patients. In retrospect, participants learned that physicians should be involved at the earliest stages of critical pathway development and in the process of implementation.  (Abstract by: Author)

204.    Meyer, J. W., & Feingold, M. G. (1993). Using standard treatment protocols to manage costs and quality of hospital services. Hospital Technology Series, 12(7), 1-23.
Abstract: The current health care environment has made it critically important that hospital costs and quality be managed in an integrated fashion. Promised health care reforms are expected to make cost reduction and quality enhancement only more important. Traditional methods of hospital cost and quality control have largely been replaced by such approaches as practice parameters, outcomes measurement, clinical indicators, clinical paths, benchmarking, patient-centered care, and a focus on patient selection criteria. This Special Report describes an integrated process for strategically managing costs and quality simultaneously, incorporating key elements of many important new quality and cost control tools. By using a multidisciplinary group process to develop standard treatment protocols, hospitals and their medical staffs address the most important services provided within major product lines. Using both clinical and financial data, groups of physicians, nurses, department managers, financial analysts, and administrators redesign key patterns of care within their hospital, incorporating the best practices of their own and other institutions. The outcome of this process is a new, standardized set of clinical guidelines that reduce unnecessary variation in care, eliminate redundant interventions, establish clear lines of communication for all caregivers, and reduce the cost of each stay. The hospital, medical staff, and patients benefit from the improved opportunities for managed care contracting, more efficient hospital systems, consensus-based quality measures, and reductions in the cost of care. STPs offer a workable and worthwhile approach to positioning the hospital of the 1990s for operational efficiency and cost and quality competitiveness.  (Abstract by: Author)

205.    London, J. (1993). On the right path. Collaborative case management makes nurses partners in the care-planning process.  Health Progress, 74(5), 36-8.
Abstract: The quality improvement movement in healthcare has given nurses a greater role in developing and implementing collaborative case management processes. In the case management model, nurses no longer simply take orders but actively participate in designing a plan of care. At Mercy Health Center, Oklahoma City, nurses play a leading role in the development of "clinical pathways," plans of care for a single diagnosis as directed by a specific physician or group of physicians. The pathways promote multidisciplinary, interdepartmental cooperation in patient care. Since August 1992, Mercy has developed clinical pathways for five inpatient and outpatient procedures, and more are being considered. Once a plan has been created, its key points are rewritten in lay terms and printed in a brochure for the patient. During the treatment, nurses and other healthcare professionals document when specific steps in the plan have been completed. In follow-up evaluations Mercy's steering committee for the collaborative care process has found that the clinical pathways have maximized quality, improved efficiency, increased patient satisfaction, and enhanced collaborative team practice.  (Abstract by: Author)

206.    Fowler, M. E. (1993). Commentary on The Nursing Case Management Computerized System: meeting the challenge of health care delivery through technology [original article by DiJerome L appears in COMPUT NURS 1992;10(6):250-8]. ONS Nursing Scan in Oncology, 2(3), 19.
Abstract: SYNOPSIS: The delivery of health care is changing at a frantic pace. Many institutions are investigating, implementing, and tailoring new practice delivery methods to meet this challenge. This article reviews how one healthcare setting has computerized their case-management process to provide a multidisciplinary, comprehensive, cost-effective patient care system. The nurse case-management computer system runs on a PC using a standard software package that is mainline compatible. On-line critical paths are in a flow sheet and formatted by DRGs. Patient outcomes are nursing-diagnosis based and broken down into intermediate goals. Following selection of intermediate goals, corresponding intervention options appear. This computerized system addresses all disciplines -- nurse, physician, and allied health professionals -- who will care for the patient during a hospital stay. [Original article accession number: 1993157283 (care plan, forms)]

207.    Eastes, L. (1993). Commentary on The clinical process and the quality process [original article by Berwick D appears in QUAL MANAGE HEALTH CARE 1992;1(1):1-8]. ENA's Nursing Scan in Emergency Care, 3(3), 14.
Abstract: SYNOPSIS: Finding effective ways to integrate physicians into the quality-improvement (QI) movement within the hospital remains a dilemma for many professionals. This well-known author proposes several methods designed to entice physicians into the QI process and convince them of QI's utility for medical practice. Steps include reallocating committee and meeting times, inviting physicians to volunteer, formalizing involvement (i.e., paying them for their time), giving specific tasks to involve them, and connecting QI to practice guidelines and critical paths. Physicians are more likely to respond to data than to conceptual or anecdotal discussions. The author also explores the relationships and similarities between QI and clinical science. It is important to involve physicians in QI activities from the onset

208.    Schweickert, R., & Wang, Z. (1993). Effects on response time of factors selectively influencing processes in acyclic task networks with OR gates. British Journal of Mathematical & Statistical Psychology, 46 ( Pt 1), 1-30.
Abstract: The mental processes involved in performing some tasks can be represented as directed arcs in an acyclic network. A path directed from the head of one arc to the tail of another indicates that the process represented by the first arc must be executed prior to the process represented by the second arc. If there is no directed path from one arc to another, the corresponding processes can be executed concurrently. Information about the arrangement of processes in an acyclic network can be found from the effects on response times of factors selectively influencing the processes. The methodology was developed earlier for critical path networks, in which a process begins execution when all its immediate predecessors have finished. This paper considers shortest path networks, in which a process begins execution as soon as any immediate predecessor is finished. Results analogous to those for critical path networks are reported. New results are presented enabling investigators to distinguish sequential and concurrent processes in both critical path and shortest path networks. This information is sufficient to construct an acyclic network representing the processes. Further, by examining the effects of selectively influencing processes, one can determine whether a task network is a critical path network or a shortest path network

209.    Luttman, R. J., Falconer, J. A., Roth, E. J., Sutin, J. A., Strasser, D. C., & Chang, R. W. (1993). The critical path method alone does nothing to improve performance. Qrb. Quality Review Bulletin, 19(5), 142-3.

210.    Luttman, R. J. (1993). The critical path method alone does nothing to improve performance [letter; comment]. Qrb. Quality Review Bulletin, 19(5), 142-3.
Notes: Comments: Comment on: QRB Qual Rev Bull 1993 Jan;19(1):8-16

211.    Hampton, D. C. (1993). Implementing a managed care framework through care maps. Journal of Nursing Administration, 23(5), 21-7.
Abstract: Managed care frameworks are a viable approach to quality improvement initiatives. The author discusses one hospital's experience with care maps as the tool used to implement managed care. A patient care guide for open heart surgery patients is used to illustrate patient and family involvement in care

212.    D'Aquila, N. W. (1993). Facilitating inservice programs through PERT/CPM. Project Evaluation and Review Technique/Critical Path Method. Nursing Management, 24(5), 92-4, 96.
Abstract: Project Evaluation and Review Technique (PERT) and the Critical Path Method (CPM) are used primarily in industrial settings to manage the efficiency and cost effectiveness of projects. Simultaneous use of these approaches can be applied to planning nursing inservice programs, seminars and workshops

213.    Nelson, M. S. (1993). Critical pathways in the emergency department. Journal of Emergency Nursing, 19(2), 110-4.
Abstract: The actual development of the CP is an easy undertaking that an experienced emergency nurse can accomplish. The important points to remember are as follows: (1) include all disciplines that provide patient care in the development of the CP, (2) use realistic time frames (i.e., those currently found to be true in the emergency department, not those that are perceived to be ideal), (3) thoroughly educate the staff about the value of the CP in the emergency department, and, finally, (4) make sure that staff members know how to document variances. CPs in the emergency department give physicians and nurses common ground on which to negotiate patient care management more efficiently and effectively. They are a logical way to bring case management into the acute care setting. With the cost of ED visits continually rising, patient acuity levels increasing, and resources declining, expedient, coordinated, multidisciplinary action is crucial in giving total quality care to each patient

214.    McGarvey, R. N., & Harper, J. J. (1993). Pneumonia mortality reduction and quality improvement in a community hospital.  Qrb. Quality Review Bulletin, 19(4), 124-30.

215.    Graybeal, K. B., Gheen, M., & McKenna, B. (1993). Clinical pathway development: the Overlake Model. Nursing Management, 24(4), 42-5.
Abstract: Overlake Hospital Medical Center has developed a multi-faceted Care Management Model to improve clinical and fiscal outcomes for selected patient populations. The Clinical Pathway Component of this model has been applied to high-volume, high-loss DRG groups. Success of the program can be attributed to the unique multidisciplinary problem solving approach, team building and a focus beyond the inpatient hospital stay

216.    Solovy, A. T. (1993). Champions of change. Today's CFOs learn to say 'yes' to TQM, patient-centered care and critical paths. Hospitals, 67(5), 14-9.
Abstract: Still clinging to that old image of the hospital CFO as the person with the green eye shades and columnar paper who always says 'no'? Forget it. Today's CFO is a coach, teacher, leader and strategist. The new CFO is also a facilitator, actively finding ways to promote change, and actively finding ways to say "yes". At the root of this change is the CFO's involvement in initiatives--particularly TQM/CQI, patient-centered care and critical paths programs--that require a completely new approach to internal financing. In the process, inter-departmental relations at those hospitals are changing dramatically as well

217.    Schryer, N. M. (1993). Nursing case management for children undergoing craniofacial reconstruction. Plastic Surgical Nursing, 13(1), 17-28.
Abstract: With consumers and providers alike expressing dissatisfaction with today's health care delivery system, case management has helped to achieve an effective balance among expected outcomes, the process of care delivery, and cost. This article describes nursing case management for children undergoing craniofacial reconstruction and how case management plans can be implemented.  (8 ref)

218.    Nyberg, D., & Marschke, P. (1993). Critical pathways: tools for continuous quality improvement. Nursing Administration Quarterly, 17(3), 62-9.

219.    Marschke, P., & Nolan, M. T. (1993). Research related to case management. Nursing Administration Quarterly, 17(3), 16-21.

220.    Ling, K. (1993). On the scene: managed care at the Johns Hopkins Hospital... initiation and evaluation of managed care.  Nursing Administration Quarterly, 17(3), 54-8.

221.    Ferguson, L. E. (1993). Steps to developing a critical pathway. Nursing Administration Quarterly, 17(3), 58-62.

222.    Breedlove, T. (1993). Managing quality--the strategy for survival. Managed Care Quarterly, 1(2), 13-4.
Abstract: Everywhere I go today, health care management is saying all the latest words--total quality management, continuous quality improvement, benchmarking, critical pathways--but most are doing the same old stuff. Saying it and doing it are quite different. What has worked in the past will not be good enough for the future. Making the change is not optional, it is the price of admission to the marketplace.  (Abstract by: Author)

223.    Samson, L. F. (1993). Commentary on The critical path: an evaluation of the applicability of nursing case management in the NICU [original article by Neidig JR et al appears in NEONAT NETW 1992;11(5):45-52]. Nursing Scan In Administration, 8(2), 15.
Abstract: SYNOPSIS: The authors conducted a retrospective chart review to determine the applicability of nursing case management to the population in a midwestern neonatal intensive care unit. The specific aims of the study were (1) to assess whether a critical pathway developed for normally growing premature infants reflected the current delivery of nursing and medical care, and (2) to determine whether this critical path facilitated care delivery to this patient population. Sixteen infant charts were included in the final data analysis. Data were collected and analyzed against a critical path based on the infants' progress through weight zones beginning at 1,500 am. Each weight zone covered a 100-gm increment and described four major categories of care -- diet, activities, tests/consults, and discharge planning/teaching. Descriptive statistics were used to analyze the data. Several different parameters were evaluated to predict length of stay and time of discharge. The method of retrospective chart review, as well as the small sample size, proved to be major limitations of the study. Lack of documentation prevented clear evaluation of progress through the critical path. The study delineated problems with the existing pattern of care delivery and spurred the authors to make changes in care delivery. [Original article accession number: 1992150111 (research, tables/charts)]

224.    Puetz, B. E. (1993). Where are the nurses?... develop and implement critical pathways. Journal of Nursing Staff Development, 9(2), 61.

225.    McAlindon, M. N. (1993). Commentary on Better planning needed to strengthen patient care systems [original article by Jacobsen T et al appears in COMPUT HEALTHC 1992;13(10):20-6]. Nursing Scan In Administration, 8(2), 18.
Abstract: SYNOPSIS: This journal conducted a survey to determine how healthcare organizations are addressing the need for patient-centered information management and how they are using technology to provide, support, and monitor patient care quality. The survey sampled 50 hospitals nationwide to identify operational change activities, clinical applications, and systems architecture designed for patient care. Computer applications in these hospitals were found to support operations rather than patient care delivery. However, patient care systems being planned included patient scheduling, centralized clinical data bases, case management, and ad hoc queries. Systems planned for point-of-care documentation included care planning, case management, and medication administration. Four major operational activities reported by the responding hospitals were revamping of the charting process, involving clinicians in information systems planning, shifting the focus from quality to an outcome orientation, and engaging in benefits-realization studies. The concept of case management was important to all respondents. A migration was noted from the traditional care plan to multidisciplinary plans ,referred to as critical paths, a core component of the case-management process. The patient care applications needed to support documentation at the point of care were found in fewer than 14% of the hospitals surveyed. Installation of case-management systems and the measurement of quality outcomes were identified as key operational changes taking place

226.    Brown, B. S., & Smith, R. J. (1993). Creative solutions through utilization management. Leadership in Health Services, 2(2), 25-9.
Abstract: In this second and concluding report on utilization management practices at Lions Gate Hospital in British Columbia, the authors outline various initiatives that improve efficiency and increase quality of care. Topics explored are laparoscopic cholecystectomy as an example of new technology that can save time and resources, a home IV therapy program, co-ordinating care by means of coordinated care mapping, and improving operating room efficiency through rigorous scheduling.  (Abstract by: Author)

227.    Spath, P. L. (1993). Critical paths: a tool for clinical process management. Journal of Ahima, 64(3), 48-58.

228.    Kibbe, D. C., Bentz, E., & McLaughlin, C. P. (1993). Continuous quality improvement for continuity of care. Journal of Family Practice, 36(3), 304-8.
Abstract: BACKGROUND. Continuous quality improvement (CQI) techniques have been used most frequently in hospital operations such as pharmaceutical ordering, patient admitting, and billing of insurers, and less often to analyze and improve processes that are close to the clinical interaction of physicians and their patients. This paper describes a project in which CQI was implemented in a family practice setting to improve continuity of care. METHODS. A CQI study team was assembled in response to patients' complaints about not being able to see their regular physician providers when they wanted. Following CQI methods, the performance of the practice in terms of provider continuity was measured. Two "customer" groups were surveyed: physician faculty members were surveyed to assess their attitudes about continuity, and patients were surveyed about their preferences for provider continuity and convenience factors. RESULTS. Process improvements were selected in the critical pathways that influence provider continuity. One year after implementation of selected process improvements, repeat chart audit showed that provider continuity levels had improved from .45 to .74, a 64% increase from 1 year earlier. CONCLUSIONS. The project's main accomplishment was to establish the practicality of using CQI methods in a primary care setting to identify a quality issue of value to both providers and patients, in this case, continuity of provider care, and to identify processes that linked the performance of health care delivery procedures with patient expectations

229.    Greaser, T., Kemph, R., & Burns, D. (1993). Nursing case management in a rural setting. Kansas Nurse, 68(3), 3-4.

230.    Trella, R. S. (1993). A multidisciplinary approach to case management of frail, hospitalized older adults. Journal of Nursing Administration, 23(2), 20-6.
Abstract: Case management has been operationally defined in many ways, depending on the model and the needs of the population. This article describes a multidisciplinary resource utilization model of case management in a geriatric acute care medical unit that differs from many nursing- and protocol-driven case management models. The author discusses the design, implementation, and outcomes, which include improved quality of care, decreased length of stay, improved financial results, and increased physician compliance.  (8 ref)

231.    Johnson, R. L. (1993). Total shoulder arthroplasty. Orthopaedic Nursing, 12(1), 14-22.
Abstract: Shoulder arthroplasty in the modern era was first performed in 1951. Total shoulder arthroplasty (TSA), which includes replacement of the articulating surface of the glenoid, dates to 1973. The intervening 20 years have witnessed multiple prosthetic and surgical approaches. Because the shoulder lacks a true bony socket it relies heavily on the support and integrity of its soft tissue for stability through its extensive range of motion. TSA is a complex and technically demanding procedure. It is however, routinely successful in skilled surgical hands. This article reviews the history of TSA, highlights recent advances and projects future trends and advances. An interdisciplinary Critical Path for short-term recovery is presented. Concluding commentary addresses long-term recovery

232.    Gevers, M., Hack, W. W., Ree, E. F., Lafeber, H. N., & Westerhof, N. (1993). Calculated mean arterial blood pressure in critically ill neonates. Basic Research in Cardiology, 88(1), 80-5.
Abstract: Mean arterial pressure (MAP) is the area under the pressure wave form averaged over the cardiac cycle. A widely used rule of thumb to estimate MAP of peripheral arterial pressure waves in adults is adding one-third of the pulse pressure (PP) to diastolic arterial pressure (DAP). However, radial artery pressure waves in newborns differ from those in adults and resemble proximal aortic pressure waves, so that the above-mentioned calculation of MAP may not be correct. The present study was set up to obtain an arithmetical approximation to derive MAP from blood pressure waves measured in the radial artery of the neonate. We accurately recorded about 300 invasively obtained blood pressure curves in the radial artery of 10 neonates admitted for intensive care. We found that MAP in the radial artery in these neonates can be well approximated by adding 46.6% PP to DAP (range 43.0-50.1%). We suggest that the rule of thumb to derive MAP from radial artery waves in the neonate to be approximately the average of systolic and diastolic pressure, as opposed to adding one-third of the pulse pressure to the diastolic value in the adult

233.    Clifford, P. G. (1993). Commentary on The search for what works [original article by Geehr E appears in HEALTHC FORUM J 1992;35(4):28-33]. Nursing Scan In Administration, 8(1), 18.
Abstract: SYNOPSIS: Within a few years, tools now being developed will enable outcomes management only envisioned by futurists just a few years ago. The author proposes a four-component outcome management system. First is the specification process, where purchasers of healthcare products, patients, and providers will define measurable outcomes. Second, providers will develop outcome-measurement instruments, such as critical paths and practice guidelines. Third, management information systems will integrate clinical decision support with artificial intelligence capable of analyzing the best available options for therapy. Outcome measures will drive the fourth component, continuous improvement. Outcome management offers the opportunity to understand what really works based on the results of past clinical practice

234.    Falconer, J. A., Roth, E. J., Sutin, J. A., Strasser, D. C., & Chang, R. W. (1993). The critical path method in stroke rehabilitation: lessons from an experiment in cost containment and outcome improvement [see comments]. Qrb. Quality Review Bulletin, 19(1), 8-16.
Notes: Comment in: QRB Qual Rev Bull 1993 May;19(5):142-3
Abstract: This study tested the effects of a project network technique called the Critical Path Method (CPM) on the costs and outcomes of inpatient team stroke rehabilitation. On admission to a large, academic, inpatient rehabilitation hospital adults who had a recent (< 120 days) stroke were randomly assigned to receive rehabilitation services from a team trained in CPM (N = 53) or from usual care teams (N = 68). Results showed no significant difference between groups in length of stay, hospital charges, or functional status at discharge. CPM may be effective in patient care services that are less influenced by specialization, professional issues, and external regulation and in settings where patient outcomes are relatively fixed and predictable, and medical care is integrated across institutions

235.    Ogilvie-Harris, D. J., Botsford, D. J., & Hawker, R. W. (1993). Elderly patients with hip fractures: improved outcome with the use of care maps with high-quality medical and nursing protocols. Journal of Orthopaedic Trauma, 7(5), 428-37.
Abstract: In a prospective cohort study, 51 patients were treated with standard nursing and medical treatment after sustaining a hip fracture. A second group of 55 patients was treated with high-quality medical and nursing protocols outlined on our care map. The patient groups showed no significant differences preoperatively in terms of the important variables of age, mental status, marital status, accommodation, ambulation, fracture type or fracture treatment. Postoperatively the patients were followed for a 6-month outcome. The outcome of return to their place of accommodation and their previous level of function was considered grade 1. In grade 2, the patients lost one level of function or one level of accommodation. In grade 3 they lost one level of accommodation and one level of function. In grade 4 they were dead. Overall we were able to show that the patients in the study group had a statistically significantly better outcome (p = 0.036). In addition, they had significantly fewer postoperative complications (p = 0.01) and a significantly greater number of the patients returned home within 14 days of their admission. We feel that the medical and nursing protocols outlined are generally applicable and could significantly improve the outcome overall for elderly patients with fractured hips

236.    Nzayinambaho, K., Simonis, F., Andries, E., & Brugada, P. (1993). Radiofrequency ablation for supraventricular tachyarrhythmias. European Journal of Cardiac Pacing & Electrophysiology, 3(2), 109-115.
Abstract: Radiofrequency (RF) energy given by means of an endocavitary catheter produces small lesions in the heart without adverse effects remote from the site where current is delivered. When applied to a critical pathway for initiation and/or maintenance of a cardiac arrhythmia, the arrhythmia can be cured. Radiofrequency current was used for the treatment of cardiac arrhythmias in 222 consecutive patients with paroxysmal supraventricular tachycardias. Among them, 82 patients (37%) suffered from atrioventricular nodal reentry tachycardia (AVNT), in 81 patients (36%) the mechanism was found to be atrioventricular reciprocating tachycardia using an accessory pathway, and in 59 patients (27%) radiofrequency was applied to create complete atrioventricular block because of atrial flutter/fibrillation refractory to pharmacological treatment. A successful long-term result was obtained in 81 of 82 patients (98%) with atrioventricular nodal reentry tachycardia in whom ablation was attempted, and in 77 of 81 patients (95%) with an accessory pathway. Definitive total AV block was achieved in all 59 patients (100%) with atrial flutter/fibrillation. In conclusion, radiofrequency current is highly effective in ablating accessory pathways and other arrhythmia foci and is the treatment of choice in patients with intractable supraventricular tachyarrhythmias.

237.    Musfeldt, C., & Hart, R. I. (1993). Physician-Directed Diagnostic and Therapeutic Plans: a quality cure for America's health-care crisis. Journal of the Society for Health Systems, 4(1), 80-8.
Abstract: The most effective way to improve quality is to reduce variation in the processes of providing a service. Physician-Directed Diagnostic and Therapeutic (PDDT) Plans are a proven methodology for reducing variation in clinical processes and improving the quality of care. A major part of the PDDT Plan process is the development of a critical pathway. Critical pathways are an application of Total Quality Management (TQM) principles to clinical care which have provided clear, tangible results in those hospitals committed to this process. These pathways define the processes, timelines and responsibilities associated with the patient's clinical needs from preadmission to post discharge. Representatives of the various health-care professions involved in treating the specified patient populations work together, led by a physician, to define the processes of care. When completed, everyone involved in treating the patient understands what is to be done, by whom, and when. The pathways allow clinicians to plan ahead and let the patient and family know what to expect. Through establishing standards of care, these critical pathways also reduce the uncertainty of treatment decisions and free physicians from having to practice defensive medicine, and thus reduce cost. While the most visible outcome of this process is the actual PDDT Plan, it is not necessarily the most important. The very process of designing the pathway improves intra- and interdisciplinary communication, and fosters teamwork

238.    Luttik, R., Romijn, C. A., & Canton, J. H. (1993). Presentation of a general algorithm to include secondary poisoning in effect assessment. Science of the Total Environment, (Suppl Pt 2), 1491-1500.
Abstract: A general algorithm for effect assessment on secondary poisoning for birds and mammals is presented. This algorithm (Maximum Permissible Concentration = NOECbird/mammal/BCF) was drawn up by analysing an aquatic food chain (water--fish--bird or mammal) and a terrestrial food chain (soil--worm--bird or mammal). NOECs and bioconcentration factors (BCFs) were collected for a set of selected compounds: lindane, dieldrin, cadmium and mercury in both water and soil, PCB153 only in water and DDT and PCP only in soil. BCFs for the terrestrial pathway are frequently < 1 and rarely above 10, though for the aquatic pathway BCFs up to 10(4) were found for the same compounds. By calculating MPCs for fish-eaters and comparing these to MPCs calculated for aquatic organisms, secondary poisoning could be a critical pathway for methyl-mercury and PCB153. For lindane the conclusion depends on whether a separate or combined data set is chosen for birds and mammals. By calculating MPCs for a standard soil situation and comparing these to MPCs for terrestrial organisms, secondary poisoning could be a critical pathway for cadmium and methyl-mercury

239.    Goode, C. J. (1993). Evaluation of patient and staff outcomes with Hospital-Based Managed Care. Unpublished doctoral dissertation, University of Iowa, Ames, IA.
Abstract: The purpose of this research was to evaluate patient and staff outcomes with a Hospital Based Managed Care (HBMC) intervention. A CareMap$E\sp{E\rm TM}$ and Nursing Case Management were implemented and the effects on patient satisfaction, staff collaboration, staff autonomy, and staff satisfaction were determined. The patient population selected for participation in the investigation were women on the Family Centered Maternal Child unit who had a cesarean birth. The staff selected for participation in the study consisted of staff who worked on two units; the post partum Family Centered Maternal Child unit where the intervention took place (experimental unit) and staff who worked on C-44, an obstetric and gynecology unit (control unit). The results support the use of the Hospital Based Managed Care system of delivery of care. Patients were more satisfied with their care under the new delivery system (t = 1.98, p =.02) and they were particularly more satisfied with their participation in decisions (t = 2.28, p =.01). In addition, the multidisciplinary staff who worked on the experimental unit had increased job satisfaction as they worked in the HBMC system of care delivery (F = 3.46, p =.03). Nurses who applied and were selected for Case Management positions had higher levels of collaboration (F = 14.95, p =.001) than other nurses, higher levels of job satisfaction with quality of care (F = 6.39, p =.02) than other nurses, and their autonomy increased as they worked within the HBMC delivery system (F = 3.66, p =.03). Multidisciplinary Team members also had higher levels of collaboration (F = 8.36, p =.006) than other multidisciplinary staff on the experimental unit and their job satisfaction with the quality of care they delivered increased under this new care delivery system (F = 3.08, p =.05). Results of this study indicate that Hospital Based Managed Care is a model of delivery of care that can improve quality of patient care and the job satisfaction of staff who provide care under this delivery model.

240.    Gemmel, P., & Van Dierdonck, R. (1993). Relationship between structure, process and process outcome in the operations management in hospitals. Acta Hospitalia, 33(4), 33-44+122.
Abstract: Hospitals are complex organizations. That is why operations management for hospitals is also complex. This complexity can only be dealt with through an integrated framework. We propose to use a framework with three dimensions: structure, process and outcome. The relationship between structure and process, and process and outcome can respectively be described as design and role. The design is the way structural components or resources (e.g. labor power and equipment) are expected to support the actual (production) process. Management develops a set of behaviors (role) that is expected to transform the process into some outcome. Design and the set of behaviors are fundamental decision parameters in operations management. It is difficult to implement such a theoretical framework in practice. We describe two models showing how such a practical implementation can be brought forward. The first model (the Patient-Focused Hospital) is an operations strategy with a specific view on the way the process must be managed. The most important characteristic is the focus on patients in all operations management decisions. This model is based on the finding that the way a hospital is structured, has an impact through the process on the outcome. The second model deals with the development of a tool which makes the design more visible and understandable. This tool is called Clinical Pathway. Finally the impact of the framework and the two models on operations management in hospitals is questioned.

241.    Eagar, K., Milbourne, K., & Hindle, D. (1993). Computerised care plans: provoking a quiet revolution. Australian Health Review, 16(1), 103-11.
Abstract: The Illawarra Area Health Service has been experimenting with use of computerised nursing care plans. Microcomputer software has been successfully tested in several wards and the intention is to move to implementation which will probably involve porting the software to the area-wide mainframe. The technology was recently extended to multidisciplinary care planning using the managed care/critical pathways approach. This paper describes the development process and some of the initial results.  (Abstract by: Author)

242.    Delage, C. A. (1993). Developing an outcomes measurement program. [11 refs]. In HMOs and managed care: the measure of health care reform: proceedings of the 43rd Annual Group Health Institute, June 13-16, 1993, San Francisco, California (pp. 547-567). Washington, DC: GHAA.
Abstract: This paper describes the development of an outcomes measurement program by a point-of-service managed care plan in Minneapolis-St. Paul.  A common set of clinical pathways and outcome measurements are used across eleven different hospitals, representing five different hospital systems.  The pathways and outcome measurements were developed through committees of participating health care providers in the Prudential Plus of Minnesota network.  Program development was catalyzed by a request for proposal from a health care buyers coalition of small to medium-sized employers.  The program is effective on January 1, 1993.  (11 Refs)  (Abstract by: Author)

243.    Carty, B. (1993). Information features of clinical nursing information systems: a Delphi Survey. Unpublished doctoral dissertation, Columbia University Teachers College, New York, NY.
Abstract: The purpose of this study was to identify the scope of information features for Clinical Nursing Information Systems (CNIS) deemed important in the administration of nursing care. Ninety-seven nursing information specialists representing 37 states and Canada, the majority of whom practiced in hospitals, participated in a two Round Delphi Survey. The Nursing Information Feature Survey (NIFS) tool, developed by the researcher, identified elements for a nursing information system in the delivery of patient care. The elements were divided into 6 categories: (1) Patient Specific; (2) Nursing Domain; (3) Institution Specific; (4) System Security; (5) Miscellaneous; (6) Future Features. There was a total of 70 items which were rated on a 5-point Likert scale. Items within each category were analyzed and ranked according to highest mean scores. Of the 70 items, 38 had a consensus of 80% of the panelists. An analysis of the data support the strongest consensus among the specialists was in the Patient Specific category. The categories with the least amount of consensus were the Nursing Domain and Future Feature categories. In addition, two themes emerged from the findings of the study. One was that the majority of the information features be patient-focused and integrated with other data bases. The other was that the features preferred by the panelists were complex and reflected knowledge processing rather than simple data processing. Comments by the specialists indicated a wide variance of opinion on the use of nursing models, standards of care, nursing diagnosis and critical paths in automated systems. There was also lack of agreement on what constituted nursing domain data. Demographics of the panelists support a mature group of systems users, who work with a variety of micro, midrange and mainframe system configurations. Recommendations included a survey of other populations, such as nurse administrators and nurses in different clinical settings to compare the different information needs of nurses in practice. The information features identified in the NIFS could be used as standards for evaluating and designing automated system for the delivery of nursing care.

244.    Carter, C. L. (1993). Physician practice pattern analysis: A hospital cost containment tool. Journal of Medical Practice Management, 9(3), 126-129.
Abstract: In an effort to control costs, hospital administrators increasingly are looking to physicians to increase clinical efficiency. One of the first steps in doing so involves analyses of physician practice patterns and utilization management studies. Often perceived by physicians as a threat to clinical judgment and autonomy, such efforts are, instead, absolutely vital to the long-term success of a hospital, and must involve physicians as partners. Utilization management analyses include comparison of costs for a specific procedure; criteria and protocols screen patients for the appropriateness of care; clinical pathways outline the management of cases from admission to discharge. Clinicians have a vital role in defining outlier cases and unusual situations which may fall outside of managed care contract specifications.

245.    Bertman, D., Rosenthal, T. C., Thompson, M. C., Giordano, D., & Wysong, J. (1993). Rural hospitals implementing nursing quality management: the struggle continues. [15 pages; 31 refs]. Buffalo, NY: NY RHRC.
Abstract: OBJECTIVE: This study was conducted to identify the barriers small rural hospitals confront during implementation of a nursing managed care model, and to identify principles for further program development. A management structure for implementation of practice guidelines is suggested. STUDY SETTING: Five rural hospitals from the Western New York Rural Health Care Cooperative with inpatient capacity ranging from 26-153 beds participated in the nursing managed care program initiated in 1992. STUDY DESIGN: This study is a qualitative evaluation of the nursing managed care program's implementation. DATA COLLECTION METHODS: Data sources included questionnaires administered in 1992, interviews conducted at the end of 1993, and program reports from the Cooperative. PRINCIPLE FINDINGS: Program implementation was compromised by several factors common to small rural hospitals: limited personnel resources, staff work overload, lack of full administrative and medical support, difficulty in fostering participant ownership, lack of experience with interdisciplinary projects, and infrequent admissions for specific diagnoses. CONCLUSIONS: Perceptions of quality of care are of particular concern for rural hospitals. When applied in small rural hospitals, conceptually sound practice guidelines and implementation models present barriers that are not insurmountable, but require a relatively long period of strong support and direction from hospital administration. Rural hospital networks can facilitate implementation. In order for case management programs to succeed in rural hospitals, they must be applicable to most admissions, reduce caregivers' workloads, and improve quality in a tangible way.  (31 Refs)  (Abstract by: Author)

246.    Hart, R., & Musfeldt, C. (1992). MD-directed critical pathways: it's time. Hospitals, 66(23), 56.

247.    DiJerome, L. (1992). The nursing case management computerized system: meeting the challenge of health care delivery through technology. Computers in Nursing, 10(6), 250-8.
Abstract: Does nursing case management compute? In this article, the author attempts to explain how computerizing the team plan of care and critical pathways decreases paperwork, makes it easier to develop standardized team care plans, enhances quality improvement trending, and is flexible enough to update the plan of care according to the patient's changing needs. The Nurse Case Management Computerized System puts the patient care team plan into an interactive computer program. The computer does the work of presenting the nurse with care plan options and printing a hard copy ready to implement. Use of the computer program enhances the health care team's ability to individualize the team plan of care while maintaining patient care standards. The system is also used to collect patient care data automatically and to trend for quality improvement

248.    Latini, E. E., & Foote, W. (1992). Obtaining consistent quality patient care for the trauma patient by using a critical pathway. Critical Care Nursing Quarterly, 15(3), 51-5.

249.    Petryshen, P. R., & Petryshen, P. M. (1992). The Case Management Model: an innovative approach to the delivery of patient care. Journal of Advanced Nursing, 17(10), 1188-94.
Abstract: Because of trends in the health care environment, hospitals are restructuring to innovative patient care delivery systems. The Case Management Model, with its emphasis on quality patient care and cost containment, is gaining widespread recognition throughout Canada and the United States. In this paper, the Case Management Model is described in relation to nursing practice.  (33 ref)

250.    Marr, J. A., & Reid, B. (1992). Implementing managed care and case management: the neuroscience experience. Journal of Neuroscience Nursing, 24(5), 281-5.
Abstract: The case management model for patient care in the neuroscience area was recently implemented in the neurosciences area at a tertiary care hospital. Understanding of the concepts of case management and managed care were essential to the implementation process. Clustering of case types and appointment of group leaders made the development of individual care maps a manageable task. Case management of 2 case types, Parkinson's disease and Guillain Barre syndrome are described, including the rationale for selection, care map development and education. The process of continuing education focused on operational issues regarding utilization of the map and professional issues such as health teaching responsibilities

251.    Resnick, S. K. (1992). Midwives putting great OB care on the map. Revolution, 2(3), 26-29,81-82.

252.    Coffey, R. J., Richards, J. S., Remmert, C. S., LeRoy, S. S., Schoville, R. R., & Baldwin, P. J. (1992). An introduction to critical paths. [Review] [14 refs]. Quality Management in Health Care, 1(1), 45-54.
Abstract: A critical path defines the optimal sequencing and timing of interventions by physicians, nurses, and other staff for a particular diagnosis or procedure. Critical paths are developed through collaborative efforts of physicians, nurses, pharmacists, and others to improve the quality and value of patient care. They are designed to minimize delays and resource utilization and to maximize quality of care. Critical paths have been shown to reduce variation in the care provided, facilitate expected outcomes, reduce delays, reduce length of stay, and improve cost-effectiveness. The approach and goals of critical paths are consistent with those of total quality management (TQM) and can be an important part of an organization's TQM process.  (14 Refs)  (Abstract by: Author)

253.    Palarski, V., & Washburn, S. (1992). Overcoming LVD in cardiac rehab... left ventricular dysfunction. American Journal of Nursing, 92(9), 52-7.
Abstract: Once they weren't even considered for CABG surgery, but more and more patients with left ventricular dysfunction are surviving and benefiting from it. Here's how to get them moving again.  (14 ref)

254.    Brockopp, D. Y., Porter, M., Kinnaird, S., & Silberman, S. (1992). Fiscal and clinical evaluation of patient care: a case management model for the future. Journal of Nursing Administration, 22(9), 23-7.
Abstract: The cost of healthcare within the United States continues to climb as does the number of individuals who have limited access to the healthcare system. By the year 2000, healthcare costs are predicted to comprise 15% of the gross national product. Over the last 10 years, the number of Americans who do not have financial protection from medical costs has risen dramatically. Presently, an estimated 35 million individuals have no insurance or other coverage.  (6 ref)

255.    Neidig, J. R., Megel, M. E., & Koehler, K. M. (1992). The critical path: an evaluation of the applicability of nursing case management in the NICU. Neonatal Network, 11(5), 45-52.

256.    Neal, J., & Slayton, D. (1992). Neonatal and pediatric PEG tubes... percutaneous endoscopic gastrostomy tube. MCN, American Journal of Maternal Child Nursing, 17(4), 184-91.
Abstract: A percutaneous endoscopic gastrostomy tube can be life-sustaining and life-enhancing for a child unable to eat enough to thrive.  (20 ref 5 bib)

257.    Montague, T. J., Wong, R. Y., Burton, J. R., Bay, K. S., Catellier, D. J., & Teo, K. K. (1992). Changes in acute myocardial infarction risk and patterns of practice for patients older and younger than 70 years, 1987-90. Canadian Journal of Cardiology, 8(6), 596-600.
Abstract: OBJECTIVE: To evaluate temporal changes in risk and patterns of hospital practice for acute myocardial infarction (AMI). DESIGN/PATIENTS: Retrospective analysis of age-related medical therapy and outcome of 342 consecutive patients (132 at least 70 years old and 210 younger than 70) with AMI between July 1, 1989, and June 30, 1990, and comparison with data from two previous analyses of AMI practice in 1987 (n = 207) and 1988-89 (n = 402). SETTING: Tertiary care medical centre. INTERVENTIONS: No direct interventions; results of the two previous AMI practice pattern analyses, however, were propagated during the practice time of the most recent analysis. RESULTS: In 1989-90, hospital mortality was higher (19%) among patients at least 70 years old compared with patients younger than 70 (8%) (P less than 0.01). Therapies proven by repeated clinical trials to be effective in reducing AMI risk were all used less frequently in patients aged at least 70 years: thrombolysis (20 versus 43%); beta-blockers (41 versus 62%); acetylsalicylic acid (71 versus 87%); and nitrates (86 versus 97%). Qualitatively, these age-specific patterns of AMI mortality and therapy were similar to previous studies. Quantitatively, however, comparing 1987 with 1989-90 demonstrated parallel and marked increases in the use of all proven medications in both age groups, ranging from 42 to 230% (P less than 0.01). There was also a significant overall decrease in mortality from the 1987 patient cohort (20%) to the 1989-90 cohort (13%) (P less than 0.05). The decrease in mortality was entirely due to decreased mortality within the group 70 years or older; 35% in 1987 versus 19% in 1989-90 (P less than 0.05). Mortality in the AMI patients younger than 70 years old remained unchanged from 1987 to 1989-90. CONCLUSIONS: Pattern of practice analyses were associated with, and may have contributed to, improved patient care and outcomes in AMI. Increased use of effective AMI medical therapy had a greater benefit in elderly higher risk AMI patients than lower risk younger patients. Persisting age-specific differences in AMI therapy may respond to more direct quality improvement measures, such as critical path management

258.    Wood, R. G., Bailey, N. O., & Tilkemeier, D. (1992). Managed care: the missing link in quality improvement. Journal of Nursing Care Quality, 6(4), 55-65.

259.    Lauffer, D. (1992). Integrated preadmission services and case management: the foundation for achievable patient outcomes in a hospital-based ambulatory surgery setting. Seminars in Perioperative Nursing, 1(3), 136-41.
Abstract: The forces of technology and changing payor requirements continue to move many surgical procedures to the ambulatory setting. The American Hospital Association's Hospital Statistics, 1991 indicates that more than half of all surgeries are now performed on an ambulatory or outpatient basis.  hospital-based ambulatory surgery programs must learn to fully integrate many of their traditional inpatient hospital services with the needs of the ambulatory surgery patient by developing preadmision services, as well as by adopting case management theory to continue to deliver quality ambulatory care. Copyright (c) 1992 by W.B. Saunders Company  (4 ref 13 bib)

260.    Nugent, K. E. (1992). The clinical nurse specialist as case manager in a collaborative practice model: bridging the gap between quality and cost of care. Clinical Nurse Specialist, 6(2), 106-11.
Abstract: The status of the current health care environment demands that health care providers deliver quality health care while reducing health care costs. While the nursing profession is faced with the critical issue of providing quality cost-effective care, the clinical nurse specialist (CNS) is caught in a controversy created by cost containment efforts and the nursing shortage. To provide effective yet efficient care mandates that patient care be comprehensive and integrated. This article presents a model of delivery of care that proposes the utilization of the CNS in a collaborative model of practice based upon case management. The operationalization of the model is based upon the interweaving of the role dimensions of the CNS, the goals of case management, and the components of collaborative practice into patient care.  (14 ref)

261.    Mikulaninec, C. E. (1992). An amputee critical path. Journal of Vascular Nursing, 10(2), 6-9.
Abstract: Approximately 115,000 lower extremity amputations (50 per 100,000 in the general population) were performed in 1985. Successful rehabilitation of these patients is contingent upon comprehensive coordination of in-patient care and education of patients and families, coupled with effective discharge planning and follow-up. In an environment that places emphasis on shortened length of stay, an efficient method to a unified multi-disciplinary approach is more difficult than ever to accomplish. "Critical Pathways" are an effective tool to expedite the communication and planning required to achieve a timely discharge as well as successful rehabilitation

262.    Zander, K. (1992). Focusing on patient outcome: case management in the 90's. DCCN - Dimensions of Critical Care Nursing, 11(3), 127-9.

263.    Simmons, F. M. (1992). Developing the trauma nurse case manager role. DCCN - Dimensions of Critical Care Nursing, 11(3), 164-70.
Abstract: The case manager serves as the coordinator of all care for a specific caseload of patients throughout an episode of illness. This role includes management, clinical, consultation, education, and research roles. Case management is especially important to implement for trauma patients who otherwise have wide variations in outcomes because of the trauma and concomitant social problems. This author describes how the case management role can be implemented, includes a sample job description of the multiple-responsibilities, and provides a case study demonstrating the case manager's role.  (5 ref)

264.    Weber, D. O. (1992). Clinical pathways stretch patient care but shrink costly lengths of stay at Anne Arundel Medical Center in Annapolis, Maryland. Strategies for Healthcare Excellence, 5 (5), 1-9.

265.    Robinson, J. A., Robinson, K. J., & Lewis, D. J. (1992). Balancing quality of care and cost-effectiveness through case management. Anna Journal, 19(2), 182-8.
Abstract: The changing climate within the health care system has necessitated the exploration of innovative strategies to provide quality-based cost-effective care. At a time when cost, quality, and efficiency are key issues, communication and coordination are crucial. Through a deliberate, collaborative approach to goal-directed care, case management facilitates the linking of quality and cost-effective care.  (4 ref)

266.    Goodwin, D. R. (1992). Critical pathways in home healthcare. Journal of Nursing Administration, 22(2), 35-40.
Abstract: Administrators and directors of home health agencies are increasingly accountable for the productive use of resources and quality patient outcomes. However, few reliable ways exist to measure and influence these components. The author proposes the use of the critical pathway typically used in acute care case management as an efficient tool to guide home health nursing practice. The author presents the process for developing a critical pathway for congestive heart failure patients in a home health agency, as well as results of a study determining when nursing interventions were implemented

267.    Mosher, C., Cronk, P., Kidd, A., McCormick, P., Stockton, S., & Sulla, C. (1992). Upgrading practice with critical pathways. American Journal of Nursing, 92(1), 41-4.

268.    Oosterhuis, L. (1992). Radiological aspects of the non-nuclear industry in The Netherlands. Radiation Protection Dosimetry, 45(1-4 SUPPL.), 703-705.
Abstract: The non-nuclear process industry supplies a considerable contribution to the radiological pollution of the environment. The main mechanisms through which the process industry may cause this pollution are flue gases, dust, water emissions, solid waste and scales. The critical pathways of exposure are the consumption of mussels, shrimps and fish, and inhalation in the vicinity of factories with air discharges. According to the Dutch environmental policy a few industries cause a non-permissible risk. Measures are required to reduce the output of radionuclides.

269.    Cockram, D. H. (1992). Profiles, functions, and career experiences of selected hospital nurse executives in the United States (1988). Unpublished doctoral dissertation, Virginia Polytechnic Institute and State University, Blacksburg, VA.
Abstract: The purpose of this study was to describe the profiles, functions, and career experiences of hospital nurse executives in the United States. A descriptive survey method was used. Data were collected from a random sampling of hospital nurse executives and chief executive officers. A self-developed questionnaire was mailed to 400 nurse executives and 300 chief executive officers. The response rate was 40% for the nurse executives and 51% for the chief executive officers. Descriptive statistics (frequencies and percentages) were used to report the findings. Results of the study revealed: (1) The profile of the hospital nurse executive was female, caucasian, married with children, and between 41 and 50 years old. Nurse executives have more baccalaureate and master's degrees than the general nurse population. Seventy-seven percent of nurse executives have a master's degree in nursing and/or related fields. Nurse executives are in a transitional role from middle to top-level hospital management with title changes, additional responsibilities and increased compensation. (2) The functions of the nurse executive position rated as very important by nurse executives and chief executive officers were similar in the categories of finance, human resource, and nursing management, and less similar in hospital/organizational management. Nurse executives were not satisfied with educational preparation in financial and hospital/organizational management. (3) The career path to the nurse executive position was identified as the traditional clinical pathway. The majority of nurse executives had worked in six or less institutions, had seven or more positions and had 13 years or more of work experience. Nurse executives stated major factors in career advancement were mentors, networking, education, management experience, strong interpersonal and communication skills, and clinical background. Nurse executives described their career planning as both internally and externally determined. Only a small number planned their careers, and over one-half were determined by the organization. Nurse executives perceived themselves as successful. Recommendations for further research were offered.

270.    Bejciy-Spring, S. M. (1991). Nursing case management: application to neuroscience nursing. Journal of Neuroscience Nursing, 23(6), 390-7.
Abstract: The changing health care environment has challenged nurses to develop creative care delivery systems that provide for quality, comprehensive, cost-effective care in a time of restricted reimbursement and diminishing human and material resources. Nursing case management has been identified as one such approach to health care delivery that has resulted in quality, patient-centered care and improved resource utilization. The case management plan, critical path and discharge planning sheet are primary tools in this care delivery model. Because of the diverse case types and variety of patient care settings, neuroscience nursing is an ideal arena for implementing a nursing case management model of care

271.    Metcalf, E. M. (1991). The orthopaedic critical path. Orthopaedic Nursing, 10(6), 25-31.
Abstract: Health care providers, purchasers, and insurers are struggling to manage the cost of health care while maintaining the quality of care. Alliant Health System has incorporated Total Quality Management (TQM) and the Critical Path Process throughout the corporation as a managed care strategy to deliver cost-effective quality care. Using the Critical Path Process has demonstrated a reduction in Length of Stay (LOS) and cost while maintaining quality. The success of this process depends upon an interdisciplinary and collaborative approach among health care providers in identifying practice patterns to assure appropriate and timely delivery of patient care

272.    Rieg, L. S., & Jenkins, M. (1991). Burn injuries in children. [Review] [59 refs]. Critical Care Nursing Clinics of North America, 3(3), 457-70.
Abstract: The overall outcome for every patient is to attain the maximum level of physical and psychosocial functioning possible within their capacity. This is individualized and impacted by the severity of injury, interventions, and subsequent outcomes along the critical path to recovery. Identification of issues, whether physical or psychosocial, in a timely manner and the development of an individualized plan of care maximize the quality of care each patient receives. As the health care giver in most frequent contact with the patient and family, the nurse must serve as the coordinator of all ancillary services and the plan of care. [References: 59]

273.    Ward-Evans, S., Hodges, L. C., & Smith, J. (1991). A new role for neuroscience nurses: the case manager. Journal of Neuroscience Nursing, 23(4), 256-60.

274.    Thompson, K. S., Caddick, K., Mathie, J., Newlon, B., & Abraham, T. (1991). Building a critical path for ventilator dependency. American Journal of Nursing, 91(7), 28-31.

275.    Cohen, E. L. (1991). Nursing case management: does it pay? Journal of Nursing Administration, 21(4), 20-5.
Abstract: Hospitals can realize substantial savings from nursing case management. The author describes an investigation assessing the cost-effectiveness of this mode of patient care delivery. The results showed an overall decrease in length of stay, an increase in patient turnover, and a potential increase in patient revenues generated for the hospital. The author provides several general and socioeconomic implications relating to the importance of nursing case management to patient care and institutions' profitability.  (12 ref)

276.    Goodman, G. R. (1991). Technology assessment, transfer, and management: the implications to the professional development of clinical engineering. Journal of Clinical Engineering, 16(2), 117-22.
Abstract: Technology, as applied in healthcare, is an encompassing term for products, equipment, procedures and services allied in some way with healthcare. This paper discusses technology as the word applies to healthcare. Areas of activity under the umbrella of technology--technology transfer, technology assessment and technology management--will be defined and discussed from the standpoint of their interaction with clinical engineering. The clinical engineering profession has approached participation in each of these activities in a nonsystematic manner, resulting in limited impact and a limited role. To go beyond its present role, the profession must study the processes of technology assessment, transfer, and management to understand their components, critical paths, strengths and weaknesses. This research should be undertaken by a joint group of clinical engineers representing practitioners and academia. Existing key players or professions should be identified, the role clinical engineers wish to pursue as a professional group and the skills required to assure competency should be declared, and appropriate resources for acquiring knowledge and experience identified.  (Abstract by: Author)

277.    Sadler, J. Z., & Hulgus, Y. F. (1991). Clinical controversy and the domains of scientific evidence. Family Process, 30(1), 21-36.
Abstract: The diversity of mental health care "schools" or therapeutic perspectives poses problems in selecting and using any single therapeutic perspective. This article describes the genesis of clinical controversy--that is, how two or more therapeutic perspectives of the same clinical situation can be so different yet not necessarily differ in outcome. Ideas drawn from contemporary philosophy of science show how different "schools" derive separate, incompatible sets of scientific evidence from the same clinical situation. The school or theory determines (in part) not just what evidence is used, but what evidence is actually perceived. The authors conclude by recommending a pluralistic approach to mental health care; they map out some consequences of this pluralism and suggest some strategies for minimizing the disadvantages of "mixing and matching" therapeutic perspectives

278.    Grudich, G. (1991). The critical path system. The road toward an efficient OR. AORN Journal, 53(3), 705-14.
Abstract: Since January 1990, surgeons have been able to make their incision within 15 minutes of the scheduled time. Total joint procedures, craniotomies, open heart surgery, and thoracic surgeries have had incision times within 15 minutes of the critical path timetable. Daily analysis of activity is done by reviewing the time study. The monthly delay report is becoming a quality assurance monitor for the hospital. Reports are sent to nurse managers, the director of surgical services, and the vice president of nursing. Daily review of the time study points out trends that can be addressed before they become a major problem. For example, in one month a surgical group had three delays. An informal meeting was held with the SDS nurse manager and the surgeon. The SDS manager and I met with the business manager of the group and the problem was resolved. In another example, a surgeon established a trend of consistently being late for cases. After a brief hallway chat, the problem was identified and an agreement reached that his time would be moved to 8 AM induction time. The last example concerns equipment failures. In one month, we had 20 delays due to equipment failures. By the next month, we had reduced equipment failures to 10, and by the end of the following month, we had three delays due to equipment failure. This was achieved through accurate documentation of the failures and frequent follow-up calls until the equipment was repaired. Surgeons and anesthesiologists still complain about delays, but not as often. Using the critical path concept has improved our efficiency and our image. This is only one facet of achieving timeliness in the OR. The teamwork between the OR nursing staff, surgical nursing staff, anesthesia staff, and the surgeons makes this program successful. Daily maintenance of the path with timely follow-up keeps the path working

279.   Giuliano, K. K., & Poirier, C. E. (1991). Nursing case management: critical pathways to desirable outcomes. Nursing Management, 22(3), 52-5.

280.    Strong, A. G., & Sneed, N. V. (1991). Clinical evaluation of a critical path for coronary artery bypass surgery patients. Progress in Cardiovascular Nursing, 6(1), 29-37.
Abstract: The critical path, one component of the case management model, was examined to determine its accuracy in describing patient recovery following coronary artery bypass surgery and to determine if variations from the path influenced postoperative length of stay. One hundred ninety-five (195) postoperative days were analyzed on 28 subjects. Data about patient characteristics, daily progress, and recovery following transfer from intensive care until hospital discharge were compared to expected patient progress and recovery as delineated by the critical path. Fifty-seven percent (57%) of the patients (n = 28) were discharged within the time frames designated by the critical path. Significant correlations (p less than or equal to .01) were found between postoperative length of stay and the variables of activity progression (r = -.46), telemetry usage (r = -.56), inspirometer use (r = -.35), and adherence to the critical path (r = -.48). Using step-wise multiple regression analysis, overall adherence to the critical path in the areas of telemetry usage and activity progression were found to be significant predictors of postoperative length of stay (combined R2 = .65)

281.    Rosenthal, J. J., de Almeida, C. E., & Mendonca, A. H. (1991). The radiological accident in Goiania: the initial remedial actions. Health Physics, 60(1), 7-15.
Abstract: The removal of a 50.9-TBq 137Cs source from a radiation therapy facility in Goiania gave rise to a radiological accident in September 1987 whose proportions were aggravated by the 16-d interval from the beginning of a series of acts that resulted in the contamination of people and areas, to the moment of identification and seeking of aid. Data gathered from the declarations of persons involved in the accident, matched with the medical assessment and radiation monitoring of areas affected, made it possible to determine procedures for care of victims and for decontaminating operations of these areas. The priorities of these procedures were to provide care to victims and eliminate critical paths by which other persons might be affected by exposure to radiation or contamination. This paper presents (1) remedial actions taken during the first weeks, (2) management problems associated with the accident, and (3) lessons learned from this episode that are of benefit to us and, hopefully, to others

282.    Osguthorpe, S. G. (1991). Collaborative practice . In C. Birdsall (Ed.),  Management issues in critical care  (pp. 83-96). St. Louis, MO: Mosby-Year Book.

283.    Bower, K. A. (1991). Standards as a bench mark of the case management approach to care delivery . In Schroeder P (Ed.),  The encyclopedia of nursing care quality: approaches to nursing standards (Vol. 2pp. 59-73). Gaithersburg, MD: Aspen Publishers.

284.    Beer, M., Eisenstat, R. A., & Spector, B. (1990). Why change programs don't produce change. Harvard Business Review, 68(6), 158-66.
Abstract: Faced with changing markets and tougher competition, more and more companies realize that to compete effectively they must transform how they function. But while senior managers understand the necessity of change, they often misunderstand what it takes to bring it about. They assume that corporate renewal is the product of company-wide change programs and that in order to transform employee behavior, they must alter a company's formal structure and systems. Both these assumptions are wrong, say these authors. Using examples drawn from their four-year study of organizational change at six large corporations, they argue that change programs are, in fact, the greatest obstacle to successful revitalization and that formal structures and systems are the last thing a company should change, not the first. The most successful change efforts begin at the periphery of a corporation, in a single plant or division. Such efforts are led by general managers, not the CEO or corporate staff people. And these general managers concentrate not on changing formal structures and systems but on creating ad hoc organizational arrangements to solve concrete business problems. This focuses energy for change on the work itself, not on abstractions such as "participation" or "culture." Once general managers understand the importance of this grass-roots approach to change, they don't have to wait for senior management to start a process of corporate renewal. The authors describe a six-step change process they call the "critical path."  (Abstract by: Author)

285.    Cooper, K. D. (1990). Psoriasis. Leukocytes and cytokines. [Review] [101 refs]. Dermatologic Clinics, 8(4), 737-45.
Abstract: Elements of the immune system must take their place alongside other potential mechanisms of psoriasis, such as psoriatic epidermal keratinocytic hyperproliferation, endothelial cell and fibroblast activation and proliferation, abnormal lipid regulation, and transmembrane signalling abnormalities. These data provide support for the concept that cellular immunologic processes are active in a manner that further promotes the patho-physiologic events observed in psoriasis. Thus, therapies useful for psoriasis may have activity on immunologic processes in addition to more traditional mechanistic conceptions of effects on keratinocyte proliferation or other constitutive cell activity. As depicted in Figure 1, UV light, steroids, cyclosporine, and tars have potent inhibitory effects on antigen-presenting cells as well as on T cells. Methotrexate and azathioprine both have immunosuppressive activities, and even retinoids have complex immunomodulatory activity in addition to their ability to alter keratinocyte differentiation (or responsiveness to lymphokines). Cyclosporine has potent effects on T cells after they encounter activating signals such as foreign antigens or autoantigens. Although the T cell actually can become partially activated in the presence of cyclosporine, the drug interferes with the ability of the activated T cell to synthesize and secrete lymphokines (such as IL-2 or gamma-interferon) critical for the initiation and amplification of immune responses to a particular antigen. Although interruption of a single critical pathway improves psoriasis, it is likely that the most effective medications for psoriasis have actions on more than one cell type important in the pathogenesis of the lesion. [References: 101]

286.    Mackety, C. J. (1990). Lasers in urology. [Review] [8 refs]. Nursing Clinics of North America, 25(3), 697-709.
Abstract: A variety of lasers are used in medicine and surgery, and the three most common lasers are argon-ion, carbon dioxide, and Nd:YAG. All three lasers are used in urology because there has been demonstrated efficacy. The genitourinary system is vital to sustain life. The kidneys regulate most of the water in the body. Their main functions are to filter the blood impurities, drain off wastes and maintain the balance of essential chemicals in the body in liquid form. The filtration process is complex but practical. The nurse needs to understand the value of using the laser for a number of urologic procedures. The advantages are decreased blood loss, precision, less damage to surrounding tissue, ability to be used through endoscopes, and possible decreasing length of stay. The patient who presents with renal dysfunction must have an in-depth work-up. Preoperative assessment will include the patient's history, both current and past, laboratory studies, and radiologic examinations. Cystoscopy can be used as part of the work-up and at the same time be used therapeutically. Assessment, planning, implementation, and evaluation do not change significantly from conventional procedures. The instrumentation, equipment, and supplies are the same with the addition of the laser and the various accessories. Laser lithotripsy has been an important adjunct to current therapy. The use of the laser for superficial bladder tumors has decreased the use of Foley catheters and the need to stay in the hospital. Other laser usage for external lesions has also proved to be efficacious. Patients entering the hospital system could benefit from a case management model of care. Case management uses critical paths to standardize managed care, facilitate discharge, promote cost-effective utilization of resources, and encourage collaborative practice, patient satisfaction, and professional satisfaction. [References: 8]

287.    Romito, D. (1990). A critical path for CVA patients. Rehabilitation Nursing, 15(3), 153-6.

288.    Vantassel, M. (1990). Effective applications of critical pathways. Michigan Nurse, 63(5), 5-6.

289.    Fiedler, K. M., Raguso, A., Morgan, G., & Renker, L. (1990). A retrospective study of graduates of a coordinated internship/master's degree program. Journal of the American Dietetic Association, 90(4), 591-6.
Abstract: The coordinated dietetic internship/master's degree program (CDI/MDP) was formed in 1965 as a consortium of three hospitals and a university combining a hospital internship and graduate degree program. As of 1984, there were 317 graduates. The purpose of this study was to determine the employment, professional activity, and further education profiles of graduates in a 20-year period. The critical path method (CPM) was used as the blueprint for the 6-month project in which 267 questionnaires were sent and 152 were returned. Findings on areas of practice of graduates of the CDI/MDP indicated that their employment generally follows the same rankings as those found in previous studies of internship, CUP, and Plan IV programs, except for greater frequency of employment in education. Activities in professional associations were notable, with many graduates serving as officers or committee members. Twenty-one percent of respondents have earned or are in the process of pursuing study beyond the master of science earned with the internship. This may indicate that students interested in completing an internship/master's program have a strong achievement orientation or that they have an unusually high regard for education. Our findings provide valuable data for understanding the career impact of advanced education combined with the internship

290.    Marinelli, G., Cerone, G., Pajewski, L. A., Porto, C., Fabiani, L., & Aloisi, P. (1989). [Radiculopathy and the organization of health services: applicability verification of a technic for analyzing time factors in diagnostic procedures]. [Italian]. Annali Di Igiene, 1(3-4), 577-90.
Abstract: The PERT is a SPR (Reticular Programation System) based on statistic-mathematic models. Since some years they are applied to productive processes to increase the efficiency and effectiveness. They all have a same base structure which is the net that is composed by the logical succession of the event and the activity which has the part of the project. Determining the minimum time (to), the maximum one (tp) and the more frequent time (tm) of each activity and applying the statistic method PERT, one gets the probable duration (te) of every activity and the critical path of the net is placed in evidence. This is formed by the chain of those activities whose duration determines the total duration of the project. The Authors have desired to verify the applicability of SPR even to the "medical industry" and, more precisely, to the diagnostic process for the verification of radiculoneuropathy. Such pathology affects a large part of the active population. The diagnostic process in this case comprises besides an accurate neurological and clinical examination of the patient, also the x-ray exam, the electromyography, the Computed Tomography (CT) and the Magnetic Resonance Imaging (MR) exam. These last two investigations gives an increase of diagnostic accuracy. With the collaboration of the physicians of the diagnostic Service, the Authors have measured in every step of the diagnostic procedure the waiting time of 48 patients with low back pain. Applying the PERT method, it has been possible to put in evidence in the net the critical activities. They are such that their duration time determines the probable duration of the whole diagnostic process. Such duration in this case it corresponds to 91 days with a standard deviation of 33 days. The delay of any critical activity causes a lealy of the whole route. This delay influences negatively on the patient's health. Besides it determines an economic damage to the system because a relation cost/time exists. The systems of reticular programmation have as objective not only the one of improving the programmation and the control of the processes, but also the attainment of an optimum cost/time ratio, varying in a way that the total cost of the realization of the process is minimum. They represent a useful criterion to direct Quality Assurance (Q.A) in the local political sanitary context, within the bounds of organization of technical - scientific quality. An accurate application of the Q.A. should modify besides the duration of the critical activities

291.    Reuben, D. B., Mor, V., & Hiris, J. (1988). Clinical symptoms and length of survival in patients with terminal cancer. Archives of Internal Medicine, 148(7), 1586-91.
Abstract: Planning terminal care for patients with malignant neoplasms is difficult, in part, because accurate measures of prognosis have not been defined. Using data from the National Hospice Study, we examined the correlation of 14 easily assessable clinical symptoms with survival in patients with terminal cancer. Performance status was the most important clinical factor in estimating survival time, but five other symptoms had independent predictive value as well (shortness of breath, problems eating or anorexia, trouble swallowing, dry mouth, and weight loss). We generated four parametric accelerated time survival models to estimate survival in patients with combinations of these symptoms and validated the log-normal model on the entire data set. This model was unaffected by patient age, sex, primary tumor type, or site. Our findings illustrate the value of biologically "soft" clinical data in predicting survival in patients with terminal cancer. The prevalence of similar symptoms among patients with cancer of various primary and metastatic sites also supports the concept of a common final clinical pathway in patients with advanced malignant neoplasms

292.    Duffield, C. (1988). Nursing managers--a time to change. Australian Health Review, 11(4), 266-9.
Abstract: The health care delivery system and the nursing profession have a dynamic relationship. The increasingly complex nature of nursing is reflected in recent industrial awards which have created a clinical career structure. The introduction of a clinical pathway should enable nursing managers to focus their attention on management issues and practices, rather than clinical problems. However, two significant barriers to effective management remain: the basis of appointment of nurses to managerial positions and the lack of management education available. Both issues must be addressed by the profession.  (Abstract by: Author)

293.    Bryant, S. (1987). Management techniques. On the critical path. Health Service Journal, 97(5062), 906.

294.    Schulte, E. H., & Scoppa, P. (1987). Sources and behavior of technetium in the environment. Science of the Total Environment, 64(1-2), 163-79.
Abstract: Technetium is a man-made element produced in increasing amounts during the last decades. The chemical and physical properties of some technetium compounds are considered, and a discussion of possible source terms is included. Literature on the environmental behavior of technetium is reviewed to evaluate its transfer and equilibrium distribution in aquatic and terrestrial ecosystems. Considerable effort has been expended in the last years in order to understand the biogeochemical processes responsible for the long-term behavior of technetium in the environment and its transfer through food chains as well as to identify critical pathways of the long-lived radioisotope Tc-99 from the environment to man

295.    Ciprian-Ollivier, J., Boullosa, O., & Bakmas, M. C. (1987). [Review and updating of the diagnostic sensibility of the dexamethasone suppression test and urinary determination of phenylethylamine and 3-methoxy-4-hydroxyphenylethylglycol in the diagnosis of endogenous depression]. [Review] [54 refs] [Spanish]. Acta Psiquiatrica y Psicologica De America Latina, 33(2), 142-8.
Abstract: 60 endogenous depressive patients (DSM III: 296.2x, 3x, 296.5x) were studied according to the following diagnostic techniques: DST (Carroll's standardization), Phenyl-ethyl-amine (PEA) urinary quantification (Spatz's technique) and 3-Methoxy-4-Hydroxyphenylethyl Glycol (MHPG) urinary quantification (Bigelow's technique). Seven groups were thus obtained according to their being positive in, at least, one of those determinations. The above mentioned techniques allow the finest of discriminations since 5% of the patients only kept undetected. The critical path analysis to this conclusion is discussed. [References: 54]

296.    Kost, G. J. (1986). Application of Program Evaluation and Review Technic (PERT) to laboratory research and development planning. American Journal of Clinical Pathology, 86(2), 186-92.
Abstract: Software for the personal computer dramatically changes the ease with which managers of research and development can use network planning to guide projects to completion in the academic medical center setting. A case study of the use of the Critical Path Method (CPM) and Project Evaluation and Review Technic (PERT) in planning and implementing transcutaneous pCO2 monitoring by a department of laboratory medicine illustrates the utility and efficiency of these network planning technics. By means of iterative PERT analyses, the project was kept on track, despite an overly optimistic estimate of the completion date initially and intense demand by clinicians for use of the new monitoring technic in the management of premature infants with respiratory disease. Additionally, the iterative management approach improved project participants' expertise in estimating and meeting deadlines. Network planning is fully adaptable to the IBM PC or an equivalent microcomputer. This article summarizes several excellent project management software packages that have become available recently

297.    Rudensky, M. (1986). Manor Care mapping strategy as long-term care industry heats up. Modern Healthcare, 16(14), 98-101.

298.    AuBuchon, J. P., & Anderson, H. J. (1986). Application of network planning methodology to workflow analysis in a reference laboratory. Vox Sanguinis, 50(2), 122-5.
Abstract: Efficient organization of the workflow in a reference laboratory is essential to timely resolution of serological problems. This study investigated the usefulness of network planning methods to streamline workflow in a blood center reference laboratory. The investigation of a patient serological problem which included a positive direct antiglobulin test was chosen for analysis. Individual steps in the resolution process were identified. All possible logical sequences of these steps were investigated to determine which steps were along the 'critical path', the sequence of steps which is rate-limiting. By implementing new procedures for these steps, faster resolution of a problem should result. The Program Evaluation Review Technique predicted that altering procedures to shorten 3 steps (autoadsorption, antibody identification panel at 37 degrees C and screening for antigen-negative units) would result in a decrease in the time required to complete a patient problem by 29%. Time-motion studies documented a 35% improvement in problem resolution time with the new procedures (p greater than 0.05). Utilization of the network planning techniques in an immunohematological laboratory may allow for more efficient and expedient operation