Care Maps, Clinical Paths/Pathways, Critical Paths/Pathways 1995-96/Oct 99

     1.    Spurr, C. D., Flammini, S., & Fisher, D. G. (1996). Automating critical pathways: one hospital's initial experience. Healthcare Information Management, 10(4), 87-104.

     2.    Shulkin, D. J., & Marris, C. M. (1996). Coordinating initiatives in critical pathways and information systems. Quality Management in Health Care, 4(2), 37-41.
Abstract: Health care providers have begun to use critical pathways and order sets to standardize clinical care in order to improve clinical resource management. This article describes ways that critical pathways and order sets can be developed and implemented in a coordinated manner. This approach allows for a process that facilitates automation of critical pathways variance analysis and continuous feedback to clinicians.  (Abstract by: Author)

     3.    Schwantes, V. D. (1996). Evolving mapping and case management for capitation. Part II: the problems and promises of databases. New Definition, 11(1), 1-2.

     4.    Hicks, L. L., & Bopp, K. D. (1996). Integrated pathways for managing rural health services. Health Care Management Review, 21(1), 65-72.
Abstract: Rural providers must redefine their role in the changing health care system to include a more integrated approach to health care delivery. The rural provider must develop integrated pathways to coordinate all medical, behavior, and social services to ensure that appropriate services are available, locally or through linkages with other providers, for the population. The integrated pathway must manage care across the continuum of services and coordinate decisions occurring at the point of service

     5.    Fox, S. W., Anderson, B. J., & McKinley, W. O. (1996). Case management and critical pathways: links to quality care for persons with spinal cord injury. American Rehabilitation, 22(4), 20-5.
Abstract: Changes in the healthcare environment and reimbursement practices have resulted in profound restructuring of traditional healthcare delivery and practice patterns throughout the country (Messier, 1994). The development of systems of cost-effective quality health service is the challenge the healthcare industry faces. One such system, a frequently used model of nursing care delivery in acute care settings, is case management (American Hospital Association, 1990). The purpose of this article is to share our approach to the development of this innovative system.  (11 ref)

     6.    Brailer, D. J. (1996). Clinical decision support: managing quality in integrated delivery systems. Quality Management in Health Care, 4(2), 24-33.
Abstract: Delivery of health care services under financial risk requires clinical decision support to ensure good and improving quality at efficient costs. This article reports our first five years of experience in developing clinical decision support methods at the University of Pennsylvania and Care Management Science Corporation.  (Abstract by: Author)

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

     8.    Bouchard, E. A., & Southerland, B. (1996-1997). TBI. Stroke rehabilitation. Rehab Management: The Interdisciplinary Journal of Rehabilitation, 10(1), 110-111.
Abstract: Individualized care plans evolve with comprehensive assessment

     9.    Beckley, N. J. (1996-1997). Managed care. Rehab under managed care. Rehab Management: The Interdisciplinary Journal of Rehabilitation, 10(1), 105,116.
Abstract: The influence of managed care on rehab providers and programs

   10.    Spath, P. (1996). Do not let your clinical path efforts fall flat. Hospital Peer Review, 21(12), 167-70.

   11.    Slade, M. D. (1996). Inpatient chemotherapy path reduces LOS to three days. Hospital Case Management, 4(12), 183-6.

   12.    Rumble, S. J., Jernigan, M. H., & Rudisill, P. T. (1996). Determining the effectiveness of critical pathways for coronary artery bypass graft patients: retrospective comparison of readmission rates. Journal of Nursing Care Quality, 11(2), 34-40.
Abstract: The article describes a study performed to determine whether the use of the critical path tool made a difference in the readmission rates of patients after coronary artery bypass graft (CABG) surgery compared with CABG patients cared for without the critical path tool. The sample for this retrospective study consisted of 780 specific patient medical records from the medical record department. Examination of the data revealed no statistically significant difference in readmission for CABG patients cared for with critical paths and those cared for without critical paths. A comparison of hospital length of stay and surgical length of stay between the two groups however, revealed statistically significant differences between the two groups. The critical path group had a significant decrease in hospital and surgical length of stay

   13.    Rantz, M. J., Porter, R., & Burton, S. M. (1996). Preparing students for health care delivery of the future: a service education partnership. Journal of Nursing Education, 35(9), 423-5.
Abstract: In conclusion, redesigning the senior leadership management theory course in our undergraduate baccalaureate nursing program to incorporate new concepts of managed care, case management, critical paths, and multidisciplinary collaborations was successful. Providing students with a "real world" project developing critical paths provided an opportunity for them to make a contribution to an organization while learning verbal and written collaborative skills that may prove crucial to their future in nursing. Critical path development projects will be pursued until those specific needs of the organization have been met. Other opportunities will become obvious for class projects as new challenges are presented for organizations to address in this ever-changing health care delivery system

   14.    Newell, B. A. (1996). We killed the Kardex so the care path could live. Nursing Management, 27(12), 51.

   15.    McFaul, W. J., & Lyons, D. M. (1996). Strategic resource management. Journal of Healthcare Resource Management, 14(10), 9-13.
Abstract: No one in healthcare can challenge the fact that expense reduction is and will continue to be one of the primary concerns of the industry. Everyone also knows that these cost pressures are merely beginning. All indications point to a future environment of intense competition, managed care based on cost-per-covered-life reimbursement, reduced reimbursement from Medicare and Medicaid, and further reconfiguration of the industry to shift patients from in- to out-patient settings. When we focus on the future, the $64,000 question is: "What is the healthcare industry doing to control non-labor expenses, and who is responsible for this ambitious undertaking within each hospital or network?" With nearly 30% of every hospital dollar consumed by non-labor expenses, are current efforts adequate to meet future demands? This article focuses on a strategic plan for reducing non-labor expenses.  (Abstract by: Author)

   16.    Little, A. B., & Whipple, T. W. (1996). Clinical pathway implementation in the acute care hospital setting. Journal of Nursing Care Quality, 11(2), 54-61.
Abstract: A study was conducted to assess the current status of clinical path implementation for acute care cases and to explore implementation issues related to defining discharge outcomes and measuring variances in clinical paths. Results indicated that documentation, identification of critical indicators and discharge outcomes, and variance detection and correction are three core issues that must be addressed by institutions that implement clinical paths. A discussion of each of these areas is provided

   17.    Kahanovitz, N., & Pashos, C. L. (1996). The role of implantable direct current stimulation in the critical pathway for lumbar spinal fusion. Journal of Care Management, 2(6), 46-8, 53-54, 56 passim.
Abstract: Positive clinical, functional, and economic outcomes for patients receiving implantable direct current stimulation during lumbar spinal fusion suggest that this technology is appropriate to include in critical pathways for lumbar spinal fusion. The article examines the criteria for incorporation of technology into an established critical pathway and serves as a useful example of how critical care maps or critical pathways can be developed.  (17 ref)

   18.    Holst, R. (1996). Responsibility matrix for clinical pathways. Journal of Nursing Care Quality, 11(2), 3-4.

   19.    Hawkins, J. A., Minich, L. L., Tani, L. Y., Sturtevant, J. E., Orsmond, G. S., & McGough, E. C. (1996). Cost and efficacy of surgical ligation versus transcatheter coil occlusion of patent ductus arteriosus. Journal of Thoracic & Cardiovascular Surgery, 112(6), 1634-8; discussion 1638-9.
Abstract: OBJECTIVE: The purpose of this study was to compare cost and efficacy of surgical closure of patent ductus arteriosus using new critical pathway methods with outpatient transcatheter coil occlusion of patent ductus arteriosus. METHODS: Surgical techniques included a transaxillary, muscle-sparing thoracotomy, triple ligation of the patent ductus arteriosus, no chest tube, and discharge from the hospital within 24 hours. Transcatheter coil occlusion of patent ductus arteriosus was done as an outpatient procedure. Costs were compared with inclusion of all hospital and professional charges. RESULTS: From July 1994 until March 1996, 20 patients underwent coil occlusion of patent ductus arteriosus and 20 patients underwent surgical closure of patent ductus arteriosus. Duration of hospitalization was significantly less for the patients receiving coil occlusion (11 +/- 6 hours) as compared with that for the patients having surgical ligation (28 +/- 7 hours, p < 0.05). Total charges were similar for surgical ligation ($7101 +/- $408) as compared with those for coil occlusion ($7104 +/- $886, p > 0.05). Morbidity in coil occlusion included inability to occlude the patent ductus arteriosus in two patients (2/20, 10%) and residual patency in two patients (2/18, 11%). Morbidity in the surgical group included nausea and vomiting necessitating hospitalization for more than 36 hours in one patient (1/20, 5%), transient left recurrent laryngeal nerve palsy in one (1/20, 5%), and pneumothorax in two patients (2/20, 10%). There were no instances of residual patency in the surgical group. CONCLUSIONS: Transaxillary thoracotomy without tube thoracostomy and with critical pathway methods allows safe and effective ligation of a patent ductus arteriosus with early hospital discharge. This surgical method has similar cost, higher efficacy rate, and applicability in all patients as compared with newer transcatheter coil occlusion techniques for closure of a patent ductus arteriosus

   20.    Gibson, T., & Heartfield, M. (1996). Critical pathways: a critical analysis. International Journal of Nursing Practice, 2(4), 189-93.

   21.    Driscoll, D., & Caico, C. (1996). Critical pathways and mother-baby coupling. Nursing Management, 27(12), 22-5.
Abstract: Mother-baby couplet care has been utilized for more than 10 years. Both staff and patients find use of critical pathways in this managed care system to be very effective and efficient

   22.    DeMaria, A. N., Lee, T. H., Leon, D. F., Ullyot, D. J., Wolk, M. J., Mills, P. S., Fay, S. C., Brown, J. H., Flatau, C. N., & Bodycombe, D. P. (1996). Effect of managed care on cardiovascular specialists: involvement, attitudes and practice adaptations [see comments]. Journal of the American College of Cardiology, 28(7), 1884-95.
Notes: Comment in: J Am Coll Cardiol 1996 Dec;28(7):1897-8
Abstract: OBJECTIVES: This study was undertaken to determine the extent to which cardiovascular specialists are involved with and affected by managed care and to ascertain their attitudes toward it. This survey also served as the follow-up to an initial study on the subject performed by the American College of Cardiology in 1993. BACKGROUND: The initial 1993 study was performed to address the lack of any comprehensive examination of the impact of managed care on cardiovascular specialists. In 1995, to reexplore this question and follow up the 1993 findings, the College conducted a survey of its membership in the following areas: 1) physician relationship with managed care plans; 2) number of managed care contracts; 3) breakdown of revenue by payment source; 4) changes in practice in response to managed care; and 5) physician attitudes toward managed care. To the extent feasible, the 1995 questionnaire paralleled the 1993 instrument to facilitate comparisons. METHODS: A questionnaire was mailed to 5,147 practicing College members in the United States, who were categorized by specialty as pediatric cardiologists, adult cardiologists or cardiovascular surgeons. Mailings were sent to 1) all pediatric cardiologists and cardiovascular surgeons; 2) randomly selected adult cardiologists practicing in 10 states with high managed care penetration; and 3) randomly selected adult cardiologists in the nine U.S. census areas who were not practicing in the 10 states with high managed care penetration. RESULTS: Usable surveys were returned by 1,236 respondents, for an overall response rate of 24%. Involvement with at least one type of managed care organization was reported by 89% of respondents, up from 76% in 1993. Although managed care relationships had increased across physician age, region, practice and specialty, respondents indicated that, on average, well below 50% of their practice revenues stem from managed care contracts. To adapt to the managed care environment, strategic practice changes, such as joining a cardiovascular network, implementing continuous quality improvement systems and adopting clinical pathways, were being instituted by most respondent practices of nine or more physicians. Smaller groups were less active. Most respondents involved with managed care disliked its effects, particularly in clinical matters. Their attitudes toward the assumption of risk, managed fee-for-service arrangements and a private versus single-payer system show that there is no uniformity of opinion regarding the best means to contain costs and promote efficiency. CONCLUSIONS: Managed care has become an established part of cardiovascular specialist practice in the United States. Although this trend is viewed with some disfavor, most respondents are making practice changes to adapt to this new environment

   23.    Campbell, S. (1996). Cardinal Glennon designs a family-focused critical path for dying children. Health Care Strategic Management, 14(12), 12.

   24.    Bunch, D. (1996). Demand management tools help providers lower costs of care. AARC Times, 20(12), 24-27.

   25.    Brosnan, J. (1996). A patient-focused pathway for ambulatory anticoagulation care. Journal of Nursing Care Quality, 11(2), 41-53.
Abstract: Careful monitoring of ambulatory patients on anticoagulation medication is essential to prevent serious complications such as hemorrhages or blood clots. Nurse-run clinics developed in the 1980s provided some of the assistance necessary for chronic maintenance. These clinics had systems problems, however, that were frustrating for both the nurse and the patient. The article describes how multidisciplinary involvement at one medical center helped develop an anticoagulation pathway that improved service to patients and clarified and strengthened the nurse's role in the pathway

   26.    Feber, T. (1996). Speak the right language. Nursing Times, 92(48), 50-1.

   27.    Lumsdon, K. (1996). Dynamic duo. The growth of managed care is dramatically changing the way doctors and nurses work together. Hospitals & Health Networks, 70(21), 26-30, 32.

   28.    Yurko, L., & Fratianne, R. B. (1996). Clinical pathways as an education tool. Journal of Burn Care & Rehabilitation, 17(6 Pt 2), S2-3.

   29.    van Rijswijk, L. (1996). Issues in chronic wound care: where do we go from here?. [Review] [5 refs]. Ostomy Wound Management, 42(10A Suppl), 70S-72S.
Abstract: Understanding of the healing process and factors that may affect it, has increased dramatically during recent years. Clinical application of this knowledge has improved care for many patients, and helped focus attention on information deficits. To better meet patient needs and increase awareness of the value of prevention, wound care clinicians and researchers are encouraged to include Quality of Life outcomes in their goals of chronic wound care. In the absence of the results of reliability, validity and feasibility studies of existing chronic wound care guidelines, clinicians need to be aware of their potential usefulness and limitations. When reviewing wound care costs or conducting studies, it is important to define cost-effectiveness as a function of outcomes and all relevant costs. Because chronic wounds occur in every care environment, these issues require the attention of all healthcare professionals, educators, payors and patients. Wound care professionals are encouraged to disseminate existing knowledge to all providers and recipients of care. [References: 5]

   30.    Staley, M., & Richard, R. (1996). Critical pathways to enhance the rehabilitation of patients with burns. Journal of Burn Care & Rehabilitation, 17(6 Pt 2), S12-4.

   31.    Rhodes, H. (1996). Working smart: a professional practice forum. On the line: professional practice solutions. J Ahima, 67(10), 28-9.

   32.    Porta, M. (1996). Holistic managed care: recognizing pathways towards integration. Imprint, 43(5), 31-2.

   33.    Pischke-Winn, K., Wahlfeldt, L. A., & Minnick, A. (1996). Initiatives to build a competitive healthcare system: integrating service redesign and clinical pathways. Nursing Case Management, 1(5), 212-22.
Abstract: In this article, the authors describe how two separate initiatives (the redesign of hospital services and the development and implementation of clinical pathways) were integrated at an academic medical center. The lessons learned in integrating projects that were not conceived at the same time and in developing multidisciplinary teams to produce new case management tools may be used by clinicians and managers elsewhere. The service redesign project developed a role for senior, experienced nurses with clinical expertise and patient management skills to manage the care of groups of similar patients, focusing on patient outcomes. The clinical pathway project developed diagnostic related groups-based clinical pathways. The steps involved in clinical pathway development-stakeholder cooperation building, initiation of data collection tools, data analysis, implementation of the role of the expert nurse in "championing" the pathway, and evaluation of the effects of pathways-are discussed

   34.    Meisler, N., & Midyette, P. (1996). Results of a multidisciplinary approach to fast-track recovery for cardiac surgery patients. Journal of Cardiovascular Management, 7(6), 7-10-8.

   35.    McKinsey, M. F. (1996). Synchronized caring. Michigan Health & Hospitals, 32(6), 18.

   36.    McGuckin, M., Stineman, M., Goin, J., & Williams, S. (1996). The road to developing standards for the diagnosis and treatment of venous leg ulcers. Ostomy Wound Management, 42(10A Suppl), 62S-66S.
Abstract: In early 1996 the Venous Leg Ulcer Guideline was developed for the diagnosis and treatment of venous leg ulcers. In order to discuss the development of standards in general, and the Venous Leg Ulcer Guideline in particular, we first need to understand the difference between the following terms: Critical pathway, consensus statement, guideline, and standard. There are advantages and disadvantages to the use of guidelines. In the development of a guideline, endorsement by a respected colleague is important. Development of the Venous Leg Ulcer Guideline began with a consensus statement and then underwent review by a national advisory panel and national peer review through publication. A revised guideline has now been developed which will be tested in a pilot study for clinical efficacy, effect on cost, and impact on quality of life. Validation will require implementation in a prospective clinical trial. Diagnostic and Treatment Algorithm forms for the diagnosis and treatment of venous leg ulcers were developed as part of the preliminary testing of the guideline. Although guidelines do not substitute for good clinical judgement, they can encourage clinical judgement and help reduce fragmented care and the costs associated with inappropriate treatments

   37.    Marvin, J. (1996). Closing remarks... critical pathways... outcome management-based... quality. Journal of Burn Care & Rehabilitation, 17(6 part 2 Suppl ), S10-S11.

   38.    Marcinko, D. E., & Hetico, H. R. (1996). Economic outcomes analysis from an ambulatory surgical center. Journal of Foot & Ankle Surgery, 35(6), 544-9.
Abstract: In the competitive healthcare marketplace, foot surgeons are being placed under pressure to demonstrate the economic value of surgical care. The management methodology of "fiscal outcomes review" is one tool being used to evaluate such care. Initially developed for internal corporate management as an executive decision support system, the process is being used an an external cost control technique to "economically credential" providers of surgical care. Consequently, the economic outcomes analysis of a single surgical procedure represents a first attempt to gather, allocate, analyze, and interpret meaningful charge information relative to the podiatric Ambulatory Surgery Center setting. When compared with the traditional outpatient hospital setting, charge reductions are documented without compromising quality. The long-held belief that Ambulatory Surgery Center surgery is more efficient than traditional outpatient surgery, can then be corroborated

   39.    Liners Kersbergen, A. L., & Hrobsky, P. E. (1996). Use of clinical map guides in precepted clinical experiences. Nurse Educator, 21(6), 19-22.
Abstract: A common concern of preceptors and students is the mutual lack of clarity about expectations for precepted clinical experiences. In collaboration with nurse preceptors, a clinical map with clear time lines to guide students through the phases of the preceptorship was developed. Use of the map helped bring clarity and consistency to precepted clinical experiences

   40.    Lesser, M. L., Robertson, S., Kohn, N., Cooper, D. J., & Dlugacz, Y. D. (1996). Statistical and methodological issues in the evaluation of case management studies. Journal for Healthcare Quality, 18(6), 25-7, 30-1, 41.
Abstract: For the past 3 years, the nursing case management team at North Shore University Hospital in Manhasset, NY, has been involved in a project to implement more than 50 clinical pathways, which provide a written "time line" for clinical events that should occur during a patient's hospital stay. A major objective of this project was to evaluate the efficacy of these pathways with respect to a number of important outcomes, such as length of stay, hospital costs, quality of patient care, and nursing and patient satisfaction. This article discusses several statistics-related issues in the design and evaluation of such case management studies. In particular, the role of a research approach in implementing and evaluating hospital programs, the choice of a comparison (control) group, the exclusion of selected patients from analysis, and the problems of equating pathways with diagnosis-related groups are addressed.  (Abstract by: Author)

   41.    Komarek, A. G. (1996). The focus of improved profit. Nursing Economics, 14(6), 332-8.
Abstract: The Care Coordinator Model is a differentiated practice, collaborative care nursing model designed to support nurse/physician practice while crossing the entire continuum of care using the underlying concept of case management

   42.    Kealey, G. P., & Burger, M. (1996). Critical pathways in clinical practice. Journal of Burn Care & Rehabilitation, 17(6 Pt 2), S6-7.

   43.    Hunt, J. (1996). Development, implementation, and conclusions of critical pathways: walk don't run. Journal of Burn Care & Rehabilitation, 17(6 Pt 2), S7-10; discussion S10-1.

   44.    Gordon, M., Greenfield, E., & Marvin, J. (1996). The Truth about Critical Pathways in Burn Care, Nashville, Tennessee, March 16, 1996. Journal of Burn Care & Rehabilitation, 17(6 part 2 Suppl ), S1-S36.

   45.    Gordon, M. (1996). Preface... "The Truth About Critical Pathways in Burn Care," which was held at the 1996 American Burn Association meeting in Nashville, Tennessee. Journal of Burn Care & Rehabilitation, 17(6 part 2 Suppl), S1.

   46.    Gordon, M. (1996). Introduction... critical pathways in burn care. Journal of Burn Care & Rehabilitation, 17(6 part 2 Suppl), S2.

   47.    Donley, R. (1996). Nursing at the crossroads. [Review] [64 refs]. Nursing Economics, 14(6), 325-31.
Abstract: Crossroads is the term used to describe nursing's decisional grid in the post health care reform era. Four avenues of practice are laid out. Nursing's decision about clinical pathways will contribute to the future of professional nursing and help shape health care delivery. [References: 64]

   48.    Cornwell, P. (1996). Critical pathways in the QI process. Journal of Burn Care & Rehabilitation, 17(6 Pt 2), S3-6.

   49.    Clarke, H. F. (1996). Integrating evidence-based clinical tools with practice. Nursing Bc, 28(5), 19-21.
Abstract: Many nurses are beginning to incorporate evidence-based clinical practice tools, such as clinical practice guidelines, critical paths and care maps, with their nursing practice

   50.    Brown, A. (1996). Subacute case management: carpe diem. [Review] [2 refs]. Nursing Case Management, 1(5), 235-40.

   51.    Tortorice, J., Martorella, C., Harlan, K., & Gertner, H. (1996). Clinical benchmarking: carotid endarterectomy. Surgical Services Management, 2(11), 26-8.

   52.    Swanson, H. L., & Scheb, D. M. (1996). The role of the anesthesia care coordinator in preadmission testing [see comments]. AORN Journal, 64(5), 776-80.
Notes: Comment in: AORN J 1997 Jun;65(6):1038
Abstract: Surgery delays and cancellations are costly to hospitals and emotionally distressful to patients. At Sarasota (Fla) Memorial Hospital, staff members developed a critical pathway-the preanesthesia collaborative care track, called "the Track," to address problems associated with preparing patients for surgery. The track is designed to facilitate preoperative patient assessments and nursing interventions that achieve desirable patient outcomes and to enhance the delivery of quality health care to surgical patients. The RN anesthesia care coordinator of the Track assists in early patient-problem identification and ensures that appropriate clinical data are available for perioperative nurses, anesthesiologists, and surgeons to avoid last-minute delays and cancellations of scheduled surgical procedures

   53.    Rogut, L. (1996). Reshaping inpatient care: efficiency and quality in New York City hospitals. Paper Series - United Hospital Fund of New York,  1-41.
Abstract: Between 1992 and 1995, the United Hospital Fund engaged two groups of New York City hospitals in collective efforts to address crucial issues of length of stay and patient-centered care; the three-year, $1.1-million Length of Stay Initiative, which supported projects in seven New York City hospitals to identify and change practices that unnecessarily prolong inpatient stays; and the two-year, $700,000 Patient-Centered Care Consortium, through which 15 hospitals surveyed patients and received grants and technical support to design, implement, and evaluate improvements in meeting patients' expressed needs for more personalized care. Specific strategies and interventions developed and tested through the Length of Stay Initiative included continuous quality improvement programs to reduce delays and prevent duplication of diagnostic tests; clinical pathways to reduce unnecessary and inefficient variations in the treatment of common conditions and diseases; and a variety of other techniques, such as work redesign, diagnostic-specific clustering of patients, interdisciplinary design teams, and interdisciplinary rounds. Activities undertaken by the hospitals participating in the Patient-Centered Care Consortium included an initial survey of 3,423 patients and subsequent focus groups, individual interviews, and additional surveys to better understand the nature and causes of problems with care and to target, design, and test small-scale improvements. Among the first products to the consortium were patient education and information programs; daily treatment plans; improvements in the coordination of care and in teamwork among health care professionals; redesigned interpreter services, and improved methods of providing emotional support. Through their projects in the Length of Stay Initiative and Patient-Centered Care Consortium the participating hospitals learned some important lessons about what it takes to increase efficiency, improve the quality of patient care, and provide better service to patients. Strong leadership, institutional support, the involvement of medical staff, an interdisciplinary approach, an investment in staff training, the ability to work through resistance to change, systems and support for collecting performance data, and ways to evaluate how well improvements work were found to be especially key.  (Abstract by: Author)

   54.    Nikas, D. J., Freeman, J. E., Luterman, A. R., Warnken, L. C., Nenstiel, R. D., Farrell, M., & Alpert, M. A. (1996). Use of a national data base to assess perioperative risk, morbidity, mortality, and cost savings in coronary artery bypass grafting. Southern Medical Journal, 89(11), 1074-7.
Abstract: To show the usefulness of the Society of Thoracic Surgeons (STS) National Database in providing clinical and cost-related outcome data, we studied 297 consecutive patients who had isolated coronary artery bypass grafting (CABG) and who were assigned to either a "fast track" or traditional track. The observed overall mortality rate was 2.7%. The predicted mortality based on preoperative risk factors was 4.7%. Before the initiation of a "fast-track" protocol and critical pathways, the average length of stay was 8.2 days and the average cost of uncomplicated isolated CABG was $18,476. The length of postoperative stay and the cost decreased to 6.0 days and $12,427, respectively, with the application of a fast-track protocol (when appropriate) and critical pathways without affecting clinical outcomes. Use of the STS National Database provided rapid and reassessing evidence that survival and quality of care were not compromised with implementation of a cost-saving fast-track protocol and critical pathways

   55.    Morris, M. (1996). Implementation of guidelines and paths in oncology. Oncology, 10(11 Suppl), 123-9.
Abstract: At the M.D. Anderson Cancer Center, we initiated a disease management program to reduce the variability of practice and increase its effectiveness, using a model that was familiar to the faculty. Professional staff members, including physicians, nurses, and allied health professionals, were divided into groups according to disease site. Each group developed practice guidelines and collaborative care paths based on evidence in the literature and expert opinion. Desired outcomes were defined. The faculty participated in developing and implementing the program, which was viewed as a means of achieving efficient, productive management of care. Nearly 1,000 patients have been entered on the 98 paths outlined to date. Integrated information systems have been an important tool for instituting the guidelines at the point of patient care and for measuring clinical and financial outcomes. A physician-led outcomes management program should permit us to deliver high-quality care and support outcomes research while decreasing costs

   56.    Miller, F. H. (1996). The legal ramifications of the NCCN practice guidelines. [Review] [20 refs]. Oncology, 10(11 Suppl), 35-9.
Abstract: Physicians concerned about being sued for medical malpractice for following (or deviating from) a clinical practice guideline written by the National Comprehensive Cancer Network (NCCN) or otherreputable group should keep in mind one general principle: "Good medicine is good law." In other words, if a physician follows a course of action in line with the professional standard of care, regardless of whether or not he or she adheres to a particular guideline, that individual has little to worry about with regard to malpractice liability. The standard of care against which malpractice liability is measured is defined informally as "what a similar doctor would do under similar circumstances." Thus, if most oncologists observe the NCCN guidelines (or if their practice already comports with them), the guidelines will serve as the professional standard against which all oncologists' conduct will be measured. If oncologists ignore the NCCN guidelines, the malpractice standard will continue to reflect the way oncologists actually treat cancer patients. [References: 20]

   57.    Meehan, T. P., Radford, M. J., Vaccarino, L. V., Gottlieb, L. D., McGovern-Hughes, B., Herman, M. V., Revkin, J. H., Therrien, M. L., Petrillo, M. K., & Krumholz, H. M. (1996). A collaborative project in Connecticut to improve the care of patients with acute myocardial infarction. Joint Commission Journal on Quality Improvement, 22(11), 751-61.
Abstract: BACKGROUND: State-based peer review organizations (PROs) and individual hospitals are challenged to achieve their quality improvement (QI) goals with shrinking resources. In 1993-1994 the Connecticut PRO and 15 local hospitals generated a comparative QI database on acute myocardial infarction (AMI) care for 1,202 Medicare and non-Medicare patients discharged in 1992 and 1993. METHODS: A steering committee composed of hospital and PRO representatives was assembled to provide oversight. PRO staff developed a chart abstraction tool and trained hospital abstractors who collected and submitted data to the PRO for comparative analyses. Written feedback was provided to all hospitals and supplemented with onsite presentations when requested. Each hospital prepared a written QI plan based on its unique data profile. RESULTS: Opportunities for improvement were identified at all hospitals. The most commonly targeted areas for improvement included the use of thrombolytics at presentation, aspirin at presentation and at discharge, and beta blockers at discharge. Improvement interventions included staff education sessions, development of AMI critical paths and standing orders, and storage of appropriate medications in emergency departments. Self-report data from the hospitals indicate improvements in care. DISCUSSION: PROs and hospitals can augment their individual QI activities by working together to share data, resources, and lessons learned. Twenty-three hospitals are now collaborating with the Connecticut PRO on a similarly designed QI project aimed at improving the care of patients hospitalized with atrial fibrillation. This project includes a more formal means of communicating QI interventions

   58.    Mathias, J. M. (1996). 'Joint camp' gets patients back on their feet. Or-Manager, 12(11), 1-9-10.

   59.    Kovach, J. S. (1996). Need for standardization of cancer practice via nationally accepted treatment guidelines. Oncology, 10(11 Suppl), 41-3.
Abstract: The critical need for a reduction in health-care costs has revolutionized the management of a significant segment of the American health-care system. The competition, at least on the basis of cost, will continue to restrict access to care and may reduce quality. For patients with diseases such as specific cancers that have been demonstrated by reproducible methods in comparative trials to be potentially curable or strikingly ameliorated, assurance of treatment by these methods must be guaranteed. Achievement of a national consensus on cancer treatment guidelines for potentially curable cancers is needed as the benchmark of quality health-care plans for patients and payors alike. Documenting adherence to such guidelines and finding mechanisms for improving treatments for future patients remain unresolved challenges of the managed-care era

   60.    Knebel, A. R. (1996). Ventilator weaning protocols and techniques: getting the job done. AACN Clinical Issues: Advanced Practice in Acute & Critical Care, 7(4), 550-9.
Abstract: Various protocols and techniques used to facilitate the weaning process are herein summarized. The protocols were derived from the literature, a survey of critical care nurses, and personal communications with individuals who use innovative methods to expedite the weaning process and reduce costs. The protocols provide a guideline for standardizing the weaning process, but they do not negate the importance of having skilled clinicians who provide continuity in implementing the protocols. The nursing profession has the opportunity to provide leadership in reducing health care costs through implementation of standardized approaches to weaning patients from mechanical ventilatory support.  (18 ref)

   61.    Kite-Powell, D. M., Sabau, D., Ideno, K. T., Hartgraves, D., & Dahlberg, C. G. (1996). Optimizing outcomes in ventilator-dependent patients: challenging critical care practice. Critical Care Nursing Quarterly, 19(3), 77-90.
Abstract: This article examines the structure and process of a collaborative practice team established specifically to improve the quality and financial outcomes of ventilator-dependent patients in a tertiary care teaching hospital. A brief overview of descriptors regarding ventilator-dependent patients is synthesized from the literature and compared with the population at St. Luke's Episcopal Hospital in Houston, Tex. An analysis of statistically significant physiologic variances that have been found to increase mechanical ventilation time or length of stay is detailed. Focused quality initiatives are discussed. Specific criteria indicative of improved outcomes are presented along with recommendations for future improvements

   62.    Katterhagen, G. (1996). Physician compliance with outcome-based guidelines and clinical pathways in oncology. Oncology, 10(11 Suppl), 113-21.
Abstract: Outcome-based guidelines and clinical pathways in oncology were developed, implemented, and evaluated in two open-staffed community hospitals in California. These guidelines and paths were instituted in both the ambulatory and in-patient setting. Evaluation demonstrated a positive impact of these tools on outcomes and a corresponding reduction in costs. The success of a program of guidelines and clinical paths is contingent on a number of factors; however, the key to success is the meaningful involvement of physicians. Suggestions for ensuring this physician collaboration, based on our experience, are detailed

   63.    Juran, N. B., Smith, D. D., Rouse, C. L., DeLuca, S. A., & Rund, M. (1996). Survey of current practice patterns for percutaneous transluminal coronary angioplasty. SANDBAG Nursing Coordinators. American Journal of Critical Care, 5(6), 442-8.
Abstract: BACKGROUND: The increasing complexity of coronary intervention has led to variations in current patterns of nursing practice for patients undergoing routine percutaneous transluminal coronary angioplasty. In preparation for a large study examining the effects of specific nursing practices on complications at the site of vascular access, we surveyed institutions participating in a randomized phase III trial involving 4010 patients to determine current patterns of practice. OBJECTIVE: The purpose of this study was to determine the current patterns of nursing practice for patients undergoing percutaneous transluminal coronary angioplasty. METHODS: An eight-page questionnaire was completed by 70 hospitals participating in the study titled Integrelin to Manage Platelet Aggregation to Prevent Coronary Thrombosis (IMPACT II). RESULTS: The hospitals participating in this study have an average of 500 beds; 34% of the institutions do 500 to 1000 angioplasty procedures annually. At many sites (39%), heparin is infused for 12 to 18 hours after the intervention, but heparin is not infused at all in 31% of the hospitals studied. At 27% of the hospitals, arterial sheaths are removed 12 to 18 hours after angioplasty, and at 15% of the hospitals, sheaths are removed more than 18 hours after the procedure. Typically after angioplasty (36%), patients are transferred to an ICU, with a nurse-patient ratio of 1:2. Eighty-three percent of the hospitals use CareMAPs or care plans for standardization of care. Most hospitals (83%) require complete bed rest for patients who have had angioplasty, with the affected leg restrained to prevent mobility. Ninety-one percent of the hospitals reported continuing to treat the patient with bed rest for an additional 6 hours after the sheath is removed. CONCLUSION: Comprehensive nursing standards of care based on well-designed clinical trials for patients after angioplasty are not available. In the second phase of our study, we hope to correlate nursing practices with clinical outcome data to improve further the care of patients who have had angioplasty

   64.    Horowitz, C. R., Goldberg, H. I., Martin, D. P., Wagner, E. H., Fihn, S. D., Christensen, D. B., & Cheadle, A. D. (1996). Conducting a randomized controlled trial of CQI and academic detailing to implement clinical guidelines. Joint Commission Journal on Quality Improvement, 22(11), 734-750.

   65.    Hilborne, L. H., Leape, L. L., Paradis, J. J., Peterson, P., & Johns, C. (1996). Managers' roundtable. Quality outcomes in an age of uncertainty. Laboratory Medicine, 27(11), 731-735.

   66.    Harris, M. (1996). Case study. Shands Hospital/University of Florida Health System: ahead of the game in adjusting to a changing marketplace? Health System Leader, 3(9), 18-25.
Abstract: This academic medical center anticipated the effects of a managed care market and, under the leadership of a management team that was willing to take risks and embrace change, has established a healthcare network that promises a good delivery system based on clinical pathways and a secure patient base.  (Abstract by: Author)

   67.    Halvorson, C. K. (1996). Perioperative case management: a total joint experience. Surgical Services Management, 2(11), 36-9.

   68.    Forkner, D. J. (1996). Clinical pathways: benefits and liabilities. Nursing Management, 27(11), 35-8.
Abstract: Clinical paths can be powerful mechanisms to prevent malpractice litigation or they can present liability issues. Common negligence issues for nurses related to clinical paths are examined as well as crucial areas of malpractice vulnerability.  (12 ref)

   69.    Burke, M. M., & Redick, E. (1996). Use interdisciplinary approach for coronary pathway [published erratum appears in Hosp Care Manag 1997 Jan;5(1):6]. Hospital Case Management, 4(11), 167-70.

   70.    Brown, L., Deckers, C., Magallanes, A., Quiamas, D., & Deschner, S. (1996). Clinical case management: what works, what doesn't. Nursing Management, 27(11), 28, 30.
Abstract: Often, what works best depends less on a specific model, and more on choosing the right people. Two nurses were selected to role model critical path and case management principles. These clinical care coordinators focused on all involved disciplines, cost containment and quality outcomes

   71.    Bosl, G. J. (1996). Development and implementation of clinical management guidelines. Oncology, 10(11 Suppl), 247-53.
Abstract: Memorial Sloan-Kettering Cancer Center is in the process of developing a disease management system that is prospective, longitudinal, and has built-in outcome measures. These will include not only the traditional clinical outcomes of response and toxicity but also outcome measures related to patients' feelings about the healthcare environment, as well as costs. The system has three essential features: (1) standards of care, (2) information technology to integrate data, and (3) central coordination of the program through the establishment of disease management teams. This article highlights the key features of the system

   72.    Arikian, S. R., Mario, G. G., & Doyle, J. J. (1996). Building a computerized disease management operating system. Oncology, 10(11 Suppl), 223-32.
Abstract: Under the increasing pressures of the marketplace, there has been a determined move in health care toward the development of disease management systems that improve efficiency, control costs, and ensure the best possible clinical outcome. Achieving these goals requires the ability to perform global analysis of complex and dynamic systems, beginning with point-of-care data collection and including the potential for multiple interfaces along the continuum of care. Our center has developed an integrated disease management system that enables the clinician to continuously monitor and assess relevant clinical and financial information flowing through the practice, providing robust and rigorous outcomes, health economic analysis, and pharmacoeconomic analysis of care at every step in the delivery process. This paper describes the results of pilot studies of the analytic capability of the system and includes an overview of the conceptual parameters employed in its development

   73.    Feber, T. (1996). Pathways to patient care [interview by Charlotte Alderman]. Nursing Standard, 11(4), 22-4.

   74.    Morris, E., & Welsh, R. (1996). Clinical effectiveness. Heart to heart. Health Service Journal, 106(5523), 33.

   75.    Weingarten, S. (1996). Practice guidelines: how can they really guide your practice? Clinical Performance & Quality Health Care, 4(4), 222-3.

   76.    Baker, P. O., & Witt, K. L. (1996). Pathways prototype. Rt: the Journal for Respiratory Care Practitioners, 9 (6), 149-150.
Abstract: A home care company develops a respiratory care pathway in order to improve outcomes

   77.    Watzlaf, V. J., & Saul, M. (1996). Using a clinical and financial database in the development and evaluation of clinical pathways--the HIM professional's role. Journal of Ahima, 67(9), 80-5.

   78.    Watson, M. K., McDaniel, J. L., & Gibson, M. H. (1996). An innovative approach to home health education: the critical path to self-care for adults with diabetes. Home Health Care Management & Practice, 8(6), 41-51.

   79.    Stratton, L., Dempsey, E., & Cummins, L. (1996). Effective/simple variance trending. Nursing Management, 27(10), 32B, 32F.
Abstract: This article describes a simple, effective process that provides facilitated variance tracking while meeting the Joint Commission on Accreditation of Healthcare Organizations' requirement for Multidisciplinary Care Plans

   80.    Strassner, L. (1996). Give your critical paths an annual checkup. Hospital Case Management, 4(10), 158-9.

   81.    Riegel, B., Gates, D. M., Gocka, I., Medina, L., Odell, C., Rich, M., & Finken, J. S. (1996). Effectiveness of a program of early hospital discharge of cardiac surgery patients [see comments] [published erratum appears in J Cardiovasc Nurs 1997 Apr;11(3):1]. Journal of Cardiovascular Nursing, 11(1), 63-75.
Notes: Comment in: J Cardiovasc Nurs 1996 Oct;11(1):v-vii
Abstract: Managed care was the impetus for a program designed to move adult patients from acute care to the lowest level of appropriate services after cardiac surgery. Clinical pathways and a home care cardiac specialty team were the major components of the Early Discharge Program. The program was evaluated based on both financial and clinical outcomes. A convenience sample of 119 pretest patients was compared with 101 posttest patients 3 months after program implementation. Hospital length of stay decreased only 0.34 days on average, but inpatient direct variable costs decreased by an average of $1,790 per patient. Based on the 101 patients in the posttest group, $180,790 in direct variable hospital costs were saved. The largest decrease in resource use was in those patients who were discharged to home care. Complications and home caregiver burden after discharge were no higher in patients discharged early. Early discharge of cardiac surgery patients appears to be safe and cost-effective

   82.    Ramirez, J. A. (1996). Antibiotic streamlining: development and justification of an antibiotic streamlining program. Pharmacy Practice Management Quarterly, 16(3), 19-34.
Abstract: Several techniques can be applied to streamline or optimize antimicrobial therapy in the hospitalized patient. As soon as there is a documented clinical response to intravenous therapy, the antibiotic can be switched to the oral route of administration. This antimicrobial streamlining technique is called switch therapy. This article presents the development of the switch therapy concept, the good clinical outcome obtained with switch therapy in patients with community and nosocomial pneumonia, as well as the cost-savings to our institution after the implementation of this program.  (Abstract by: Author)

   83.    Namie, M. W. (1996). Establishing processes for the implementation of a total knee replacement clinical pathway. Home Health Care Management & Practice, 8(6), 33-40.

   84.    Nairn, H. (1996). Dementia care planning--Highland. Journal of Psychiatric & Mental Health Nursing, 3(5), 329.

   85.    Holden, A. C., Josephs, S., & Scantlebury, K. (1996). One solution to the early discharge controversy. Canadian Nurse, 92(9), 49-50.

   86.    Hetherington, C. L. (1996). Can you tell me how to find my way on this MAP? Journal of Emergency Nursing, 22(5), 373-374.

   87.    Hartmann, R. A. (1996). Developing critical pathways containing antimicrobial therapy. Pharmacy Practice Management Quarterly, 16(3), 60-6.
Abstract: Today's health care institutions are being challenged to provide high quality health care in the most efficient way possible. One approach taken by many organizations has been the development of critical pathways in order to minimize delays in therapy, facilitate the best outcomes, optimize resources, and maximize quality. Opportunities exist for these protocols to address a number of antimicrobial therapy issues and the multidisciplinary development process provides an excellent opportunity for pharmacist involvement.  (Abstract by: Author)

   88.    Greeson, D., & Lowenhaupt, M. (1996). Clinical reengineering. A benchmark strategy. Physician Executive, 22(10), 10-5.
Abstract: The health care provider marketplace continues to undergo dramatic changes with the advent of hospital mergers, acquisitions, and physician and hospital alliances. In this era of managed care, cost containment is still vital to a hospital's success, but many stakeholders--patients, employers, and physicians--are determined that quality of care also remain paramount. How can hospitals reduce their expenses and maintain a quality focus? The answer lies in a successful clinical reengineering initiative. One progressive model of clinical reengineering is presented, as well as examples of initiatives at three health care institutions. Initial results of clinical redesign programs have been dramatic and encouraging, with documented evidence of simultaneous cost savings and improved patient care.  (Abstract by: Author)

   89.    Fowler, S., Rodine, L., & Spivey, P. (1996). New pathway saves neonatal unit thousands. Hospital Case Management, 4(10), 151-4.

   90.    Finnegan, A. (1996). Managing cost and quality in case management. Paediatric Nursing, 8(8), 25-6.
Abstract: Anne Finnegan makes a case for managed care, but cautions nurses on the potential cost to quality.  (11 ref)

   91.    Edwards, W. H. Sr, Edwards, W. H. Jr, Martin, R. S. 3rd, Mulherin, J. L. Jr, & Bullock, D. (1996). Resource utilization and pathways: meeting the challenge of cost containment. American Surgeon, 62(10), 830-4.
Abstract: The 1990s will bring sweeping changes with managed care and capitation. To address this cost/quality paradox, selective intensive care utilization is coupled with clinical pathways as an innovative change for all patients having cerebral revascularization (CVR) or femoral revascularization (FR). From January 1, 1991 through June 30, 1995, data were accumulated on 2023 procedures in 1524 patients. The study was based on 848 CVRs and 1175 FRs. Intensive care unit (ICU) observation was necessary in 73 patients (3.6%) for cardiac or hypertensive management. Twenty-six patients (1.2%) transported to a vascular surgical floor from the postanesthesia recovery room required return to an ICU for complications during hospitalization. There were nine strokes or transient ischemic attacks (0.4%) in the CVR group, four myocardial infarctions (0.2%), and five perioperative deaths (0.3%). In the FR group, there were 14 deaths (0.9%). Readmission during the perioperative period, 30 days, was necessary in 46 patients (3.1%). Financial cost analysis revealed the mean adjusted cost for CVR in 1990 adjusted to 1995 dollars was $7223. The institution of case management reduced this to $4490 (37.8 per cent reduction in total hospital costs). The cost for FR in 1990 dollars adjusted to 1995 was $14,332 reduced to $5541 (a 59 per cent reduction in total hospital costs). This study suggests the use of clinical pathways does not impair quality of care, leads to no higher morbidity or mortality, and can produce significant cost savings to a hospital

   92.    de Bentzmann, S., Plotkowski, C., & Puchelle, E. (1996). Receptors in the Pseudomonas aeruginosa adherence to injured and repairing airway epithelium. [Review] [54 refs]. American Journal of Respiratory & Critical Care Medicine, 154(4 Pt 2), S155-62.
Abstract: In the normal respiratory tract, the airway epithelial surface is protected from pathogenic bacterial colonization by the mucociliary clearance. The mucins present in the gel mucus layer exhibit a high diversity of carbohydrate receptors that allow specific bacterial recognition followed by bacterial and mucus elimination. As soon as the mucociliary clearance mechanism is impaired, the bacterial attachment to mucins in association with mucus stasis represent critical pathways for bacterial colonization of the airway epithelium. Several sources of injury may damage the epithelial integrity and induce partial or complete epithelial shedding, exposing cellular receptors and unmasked extracellular matrix (ECM) components that can be recognized by bacterial adhesins. Laminin and type I and IV collagens represent sites of Pseudomonas aeruginosa attachment to the ECM components. During airway epithelium repair after injury, particularly in cystic fibrosis (CF), the repairing cells exhibit apical receptors such as asialylated gangliosides (asialo GM1) to which P. aeruginosa adheres. The identification of the different receptors for P. aeruginosa, present either on the ECM proteins or on the apical surface of the remodeled airway epithelium, particularly in repairing respiratory CF epithelial cells, is a prerequisite to further therapeutic strategies to prevent airway colonization by P. aeruginosa. [References: 54]

   93.    Barie, P. S., & Hydo, L. J. (1996). Learning to not know: results of a program for ancillary cost reduction in surgical critical care. Journal of Trauma-Injury Infection & Critical Care, 41 (4), 714-20.
Abstract: OBJECTIVE: Compelling internal and external influences are stimulating global re-evaluations of care standards for efficacy and cost. Critical care uses huge amounts of resources despite widespread shortages of beds and nurses. This study tested the hypothesis that ancillary expenditures can be decreased without compromising care. METHODS: Costs for laboratory tests, radiographs, blood products, nutritional supplements, and drugs were compared prospectively for all surgical intensive care unit care for two 4-month periods (January 1 to April 30, 1994 and January 1 to April 30, 1995) at a urban university center. A systematic, multidisciplinary cost-reduction program began May 1, 1994, with emphasis on laboratory and radiographic testing and procedures, and blood product, nutritional, and drug therapies. Cohorts were compared by age, Acute Physiology and Chronic Health Evaluation (APACHE) II and III admission scores, and case mix. Outcome variables were hospital mortality, days in the intensive care unit and hospital, the development of multiple organ dysfunction syndrome, and expenditures. Cost data were taken weekly from the hospital's clinical information system. No new equipment was introduced during the study period except for pumps for patient-controlled analgesia, and there were no new critical pathways or other patient care guidelines. RESULTS: Case mix and all noncost variables were identical. Overall costs were reduced by 29% when normalized by the number of patient-days in each period. Laboratory testing was reduced in frequency by 24 to 32%, and cost by 26 to 28%. Comparable reductions in the cost of blood products (32%) were exceeded by the reductions in expenditures for nutritional supplements (49%) and pharmaceuticals (45%) (all, p < 0.01 or less). Modestly increased (2%) x-ray charges in 1995 were owing entirely to insertion of prophylactic inferior vena cava filters (each, $2,800, n = 5) and computed tomography scans for sinusitis (each, $350, n = 5), although the 7% reduction in portable chest radiographs that was achieved did not meet expectations. CONCLUSIONS: Substantial reductions in physician-ordered ancillary expenditures are possible without compromising the standard of care of critically ill patients, or the support of an elaborate framework of defined care plans. With additional experience, incremental savings may accrue from refinement of successful strategies and new approaches to intractable problems

   94.    Hudson, T. (1996). Measuring the results of faith [see comments]. Hospitals & Health Networks, 70(18), 22-4, 26-28.
Notes: Comment in: Hosp Health Netw 1997 Jan 20;71(2):8
Abstract: Guiding patients to health takes more than technological wizardry, wonder drugs, and pleasantly decorated surroundings. In fact, to an increasing number of institutions, faith is the missing ingredient. Faith in a higher power. Faith in oneself. Faith in the possibilities for recovery. Welcome, then, to the new high-tech, high-touch world, where pastoral care meets managed care. The results may startle you

   95.    McAlister, F. A. (1996). The potential of critical pathways [letter; comment]. Annals of Internal Medicine, 125(5), 427-8.
Notes: Comments: Comment on: Ann Intern Med 1995 Dec 15;123(12):941-8

   96.    Rosenquist, P. B., Colenda, C. C., Briggs, J., Hardison, P., & Jane, J. (1996). Riding a Trojan horse: computerized psychiatric treatment planning using managed care principles. Managed Care Quarterly, 4(4), 89-95.
Abstract: Efforts to curtail health care costs have triggered new emphasis on resource management and accountability, entailing explicit documentation of the rationale for treatment and the resulting outcome of care. This article discusses the development of a computerized psychiatric treatment planning database that embodies principles and language of managed care, including specific admission criteria, severity ratings, and time frames for completion of interventions. The program is designed to balance goals of clinical utility, usefulness of the database as a tool for utilization review, quality improvement, and health services research, while providing an interface that is acceptable to clinicians.  (Abstract by: Author)

   97.    Nelson, E. C. (1996). Using outcomes measurement to improve quality and value. [Review] [25 refs]. New Directions for Mental Health Services, (71), 111-24.
Abstract: The relationship between quality and value is demonstrated through improvement models and case examples. Principles and special issues relevant for improvement models in mental health are discussed. [References: 25]

   98.   Lagoe, R. J., & Aspling, D. L. (1996). Enlisting physician support for practice guidelines in hospitals. Health Care Management Review, 21(4), 61-7.
Abstract: Available experience indicates that physician support is crucial if clinical pathways are to support quality of care while reducing lengths of stay and resource use. Enlisting such support requires understanding of physician perspectives concerning the quality and delivery of health care. It also requires the development of data systems as a means of communication with physicians

   99.    Fischer, M. (1996). Feature topic: the changing face of nursing practice. Tools for planning care. Journal of Gynecologic Oncology Nursing, 6(4), 20-1.

100.    Williams, D. B. (1996). Is the case manager being replaced? [editorial]. Nursing Case Management, 1(4), 153.

101.    von Degenberg, K. (1996). Focus. An effective health service: can it be achieved? Nt Research, 1(5), 340-6.
Abstract: The development and delivery of clinically effective services is a priority for the NHS and high on the agenda of clinicians and managers alike, whether in the private or public sector, in hospital or in the community. The challenges in achieving an effective clinical service are enormous, but there is much potential for success. Patients are becoming more discerning, have increasingly higher expectations and are now better informed than ever before about clinical treatment, care and therapy. An increasing number of those responsible for delivering health care are basing clinical practice on the expanding body of clinical evidence and research findings. This paper addresses some of the key components contributing to improvements in health care and describes recent developments on how this is being achieved. The paper concludes that evidence-based health care is becoming more achievable through a constantly improving knowledge base, improved technology and better ways of shared learning which aims to provide the most cost-effective health service, and one which is responsive to patients' needs and their perceptions of an effective health service.  (17 ref)

102.    Turley, K. M., & Higgins, S. S. (1996). When parents participate in critical pathway management following pediatric cardiovascular surgery. MCN, American Journal of Maternal Child Nursing, 21(5), 229-34.

103.    Spooner, S. H., & Yockey, P. S. (1996). Assessing clinical path effectiveness: a model for evaluation. [Review] [31 refs]. Nursing Case Management, 1(4), 188-98.
Abstract: Clinical paths are being developed in response to the current push to decrease healthcare costs while maintaining high quality care. Literature supports clinical path evaluation results, but few articles address a systematic evaluation process. The purpose of this article is to present a five-step evaluation model that can be followed in determining the effectiveness of clinical paths. The goal of the evaluation process is to provide reliable information and to translate the information into changes in healthcare. The article contains a graphic representation of the model, an explanation of each step, and activities to be performed. [References: 31]

104.    Nyholm, L. (1996). Benchmarking: a case report. Best Practices & Benchmarking in Healthcare, 1(5), 266-8.
Abstract: In mid 1993, administrators and physicians at Bristol Medical Center teams up with HCIA to perform clinical pathway analysis on five diagnosis related groups. The major goal of this project was to establish a partnership between the hospital administration and the medical staff to meet or beat existing benchmarks

105.    Lakier, N. (1996). Tracking care in San Diego. Health Systems Review, 29(5), 41-5.
Abstract: Standardizing care cost-effectively, while carefully tracking individual patients' progress through the care continuum, has challenged health systems around the country. In an excerpt adapted from a new book, the author, the operations strategist at ScrippsHealth, describes how one of the nation's leading integrated delivery organizations has answered the call.  (Abstract by: Author)

106.    Kearns, S., & Payne, J. (1996). Riding the care path wave: a focus on collaboration at a community hospital. Leadership in Health Services, 5(5), 17-20.

107.    Gottlieb, L. D., Roer, D., Jega, K., D'arc St Pierre, J., Dobbins, J., Dwyer, M., Lewis, S., & Manus, D. (1996). Clinical pathway for pneumonia: development, implementation, and initial experience [see comments]. Best Practices & Benchmarking in Healthcare, 1(5), 262-5.
Notes: Comment in: Best Pract Benchmarking Healthc 1997 Mar-Apr;2(2):88
Abstract: BACKGROUND: As part of a large multidisciplinary project to reduce cost, decrease hospital length of stay, and improve efficiency of patient care at Saint Mary's Hospital, a clinical pathway for pneumonia was developed and implemented. METHODS: After using analysis of severity-adjusted data to determine which conditions would be best targets for improvement, a utilization management steering committee created a multidisciplinary group to develop a clinical pathway for pneumonia. This group was led by physician champions and consisted of representatives from nursing, respiratory therapy, pharmacy, and home healthcare. With information gained from chart abstraction, which identified "best practice" patterns, guidance from the medical literature, and local expertise, this group developed a clinical pathway that included an auxiliary protocol for respiratory care and a detailed educational brochure for patients. Before implementing the clinical pathway, extensive educational activities were undertaken involving the medical staff, house staff, nurses, and other staff. Data collected on consecutive patients discharged after implementation of the pathway were compared with data collected on patients discharged before the pathway in 1994. RESULTS: For DRG 89, the patients who were on the pathway in comparison to the control patients from 1994 had a lower average length of stay by 1.45 days (5.84 vs. 7.29 days) and a lower average total charge by $1,453 ($9,511 vs. $10,964). For DRG 90, the patients who were on the pathway in comparison to the control patients from 1994 had a lower average length of stay by 1.83 days (3.45 vs. 5.28 days) and a lower average total charge by $1319 ($5450 vs. $6769). CONCLUSIONS: The pneumonia clinical pathway that was implemented was associated with reductions in the length of stay and total charges. These reductions were seen in relationship to historical controls and to patients cared for concurrently who were not placed on the pathway. Although not fully used on all pneumonia patients, the presence of the pathway probably had some positive effects even on patients not formally on the pathway, through systems changes and educational influences. The pathway also positively influenced other conditions by the use of ancillary algorithms for conditions other than pneumonia, and the more rapid administration of antibiotics for other infectious diseases. Also, lessons learned in the creation of this first pathway have been helpful in streamlining the process of future pathway development

108.    Crawford-Swent, C. (1996). Negotiating the chaos of patient care with clinical pathways. [Review] [3 refs]. Nursing Case Management, 1(4), 173-9.

109.    Cole, L., Lasker-Hertz, S., Grady, G., Clark, M., & Houston, S. (1996). Structured care methodologies: tools for standardization and outcomes measurement. [Review] [11 refs]. Nursing Case Management, 1(4), 160-72.
Abstract: In today's healthcare environment, institutions are striving to streamline processes, reduce costs of healthcare, and establish best practice patterns while maintaining and improving the quality of care provided. Various healthcare delivery models are in use including case management and outcomes management. Various tools or structured-care methodologies (SCMs) are incorporated into these different models to support cost reduction and streamline processes while enhancing quality of care. This article discusses the tools frequently used, such as critical pathways, algorithms, and guidelines, as well as how these tools can be used in combination to support each other. This article also addresses the benefits of SCMs, how these tools are developed, and how the data obtained can be used in quality enhancement programs. [References: 11]

110.    Borawski, D. B., & Snow, M. D. (1996). Pneumonia pathway streamlines care. [Review] [1 refs]. Nursing Case Management, 1(4), 180-2.

111.    Aronson, B., & Maljanian, R. (1996). Critical Path education: necessary components and effective strategies. [Review] [11 refs]. Journal of Continuing Education in Nursing, 27(5), 215-9.
Abstract: Proper use of Critical Paths based on a solid educational foundation aids caregivers in meeting the ultimate challenge of today's healthcare environment: to provide a higher quality of care at a lower cost. The components for a comprehensive educational program for Critical Paths include general principles, Path contents, Path development, guidelines for documentation, variance data collection and evaluation. A strategy to provide large numbers of staff with background information is through the use of self-learning packets; the case study approach is an appropriate strategy for Path specific education. Evaluation data indicate that both strategies are effective in assisting staff to develop and implement Critical Paths. [References: 11]

112.    Zander, K. S. (1996). Negotiating outcomes with patients and families. Seminars for Nurse Managers, 4(3), 172-7.
Abstract: Negotiating outcomes is a complex skill that is crucial to attaining quality care, particularly in an environment characterized by an accelerated speed of care and regimented options for care. In this environment, patients and their families need a realistic view of achievable outcomes. Caregivers must be able to reformulate and renegotiate outcomes quickly with patients and their families. Caregivers act as a catalyst in the outcome-achievement process and, to be successful, seek new and creative strategies to accomplish this. Being a catalyst also involves determining the patients' personal feelings about their illnesses and the proposed interventions, assisting patients in planning how to translate their new knowledge into behaviors, and to build in feedback mechanisms

113.    Wills, E. M., & Sloan, H. L. (1996). Assessing peripheral arterial disorders in the home: a multidisciplinary clinical guide. Home Healthcare Nurse, 14(9), 669-80; quiz 681-2.
Abstract: Patients with peripheral vascular diseases (PVD) have venous problems, arterial problems, or both. Although several home care clinical guidelines exist for PVD, the multidisciplinary clinical guidelines for clients with peripheral arterial diseases outlined in this article present new material for nurses and agencies who are interested in developing clinical paths for these challenging patients

114.    Williams, E. K. (1996). Guest columnist. Measure patients' progress with home SW paths. Hospital Home Health, 13(9), 105-107.

115.    Uys, L. R., Mhlaluka, N. G., & Piper, S. E. (1996). An evaluation of the effect of programme changes in an acute psychiatric unit. Curationis, 19(3), 21-7.
Abstract: This article describes a research project in which nurses evaluated the effect of changes in a unit programme in a situation where staffing and other resources are severely limited. A quasi-experimental design was used in which the situation before the change was compared with the situation after implementation of the new programme. The dependent variables were patient symptoms and interaction patterns in the unit. The study was done in an acute female psychiatric inpatient unit in a large state psychiatric hospital in South Africa with predominantly black Zulu speaking patients. It was found that the changed programme did not increase the total interactions in the unit significantly, but that it did increase neutral interactions and decreased negative interactions. It also kept the rate of interaction steady over time between patients and staff and steadily increased interaction between patients themselves. In the control group all interactions decreased over time. No significant difference was found in symptoms between the two groups. It is concluded that the structured programme in a unit may change interaction patterns positively, even when poor staffing makes it possible only to plan nursing care for groups of patients rather than individuals. Whether these changes in interaction will be transferred to family and friends in the longer term, still has to be explored

116.    Stewart, E. E. (1996). Medicare risk contracting places new demands on physician group practices. Healthcare Financial Management, 50(9), 80-83, 85.
Abstract: Physician group practices new to Medicare risk contracting face unfamiliar financial and practice imperatives. Financial imperatives include accepting capitation and the risks associated with it. Practice imperatives include adhering to critical paths and admission and discharge criteria. By familiarizing themselves with the risks and rewards of Medicare risk contracting, physician group practices can make more informed decisions about entering into such arrangements.  (Abstract by: Author)

117.    Spath, P. (1996). Lessen your path-related liability concerns. Hospital Peer Review, 21(9), 125-7.

118.    Rosenstein, A. H. (1996). Critical pathways: pluses and minuses. Journal of Healthcare Resource Management, 14(7), 40.

119.    Ringel, S. P., & Hughes, R. L. (1996). Evidence-based medicine, critical pathways, practice guidelines, and managed care. Reflections on the prevention and care of stroke [see comments]. Archives of Neurology, 53(9), 867-71.
Notes: Comment in: Arch Neurol 1996 Sep;53(9):848
Abstract: Because managed care plans are exerting enormous pressure to reduce the cost of medical care, neurologists need to enhance their skills at identifying appropriate, high-quality, and cost-effective care for patients with neurological disorders. A variety of health services research methods are available that foster evidence-based decisions and de-emphasize intuition in decision making. Despite imperfect data and a lack of familiarity with some of these methods, we have found them useful in developing guidelines and pathways for the prevention and management of stroke. Neurologists should become more familiar with the pragmatic benefits, limitations, and obstacles that hinder acceptance and implementation of these approaches. If we wish to continue to influence the medical decision process, we must focus on the provision of quality neurological care and not on the managed care plan

120.    Ramos, M. C. (1996). The pathway to good intentions [editorial]. Journal of Wound, Ostomy, & Continence Nursing, 23(5), 242-3.

121.    Parker, S., & Tomaselli, M. B. (1996). Streamlining breast disease management. Journal of Healthcare Resource Management, 14(7), 23-6.
Abstract: New technology has been developed for performing percutaneous (non-surgical) breast biopsy and tracking the outcome of breast disease patients. The procedure, mammotomy, takes a biopsy of breast tissue lesions quickly during the same office visit at which the screening mammography discovers an abnormality. Because the procedure is non-invasive, it bypasses the extra time and expense of open surgical biopsies. In conjunction with mammotomy, Breast Cancer Manager (BCM) software is intended to streamline breast care data management. These technologies provide the cornerstone of a comprehensive breast health plan that can streamline patient care across specialties. This plan uses an organ-based, multispecialty coalition of practitioners related to the diagnosis and treatment of breast disease. The BCM software provides a central, complete record of all care given to a patient from the first screening mammogram through surgery and adjuvant therapy. All practitioners will have access to its information and at the same time be able to add to it, making it the repository of patient and practice data for management analysis and outcomes reporting. This article looks at the treatment paradigm of breast disease and details the potential cost savings made possible by mammotomy and the BCM software.  (Abstract by: Author)

122.    Murphy, V. (1996). Outpatient surgery pathway sets the standard at Mercy Medical Center. Inside Ambulatory Care, 3(6), 1,4-5, insert 4p.

123.    Mohr, J. J., Mahoney, C. C., Nelson, E. C., Batalden, P. B., & Plume, S. K. (1996). Improving health care, Part 3: Clinical benchmarking for best patient care. Joint Commission Journal on Quality Improvement, 22(9), 599-616.
Abstract: BACKGROUND: Benchmarking, which shows that a much better way of doing something may be possible, stimulates local interest in changing and in making changes previously thought not possible. A PLANNING WORKSHEET: The Worksheet has five basic steps: Identify measures, determine resources needed to find the "best of the best," design a data collection method and gather data, measure the best against own performance to determine gap, and identify the best practices producing best-in-class results. CASE EXAMPLE--BOWEL SURGERY: The Accelerating Clinical Improvement Bowel Surgery Team at Dartmouth-Hitchcock Medical Center (Lebanon, NH) was formed in November 1994 to improve the care of patients with diagnosis-related group (DRG) 148 or 149. Consulting two large, administrative databases and the medical literature, the team found that a substantial gap existed between the bowel surgery delivery process and the best results, as far as they were known, among comparable organizations. After flowcharting the delivery process, the team identified the high-leverage steps: same-day services, general surgery clinic, and routine care. The team then planned three successive PDCA (plan-do-check-act) cycles: utilization of same-day services for all elective surgery patients, establishment of a standardized preoperative bowel preparation, and utilization of pre- and postoperative routine care orders. These improvement cycles resulted in a reduction in length of stay from 9.66 to 8.29 days. Implementation of a critical pathway resulted in a further reduction to 5.04 days. CONCLUSION: Benchmarking can play an integral role in clinical improvement work and can stimulate wise clinical changes and promote measured improvements in quality and value

124.    McGinnis, C., Day, L. M., & Pristave, R. (1996). What are the options for nephrologists under capitation? Nephrology News & Issues, 10(9), 21-5.
Abstract: Nephrologists will play a pivotal role in changing tomorrow's renal delivery system. Nephrologists still control patients and drive the health care delivered to patients suffering from ESRD. As a result, practice management companies, independent consulting firms, renal societies, hospitals, dialysis providers, insurance companies, managed care plans, government agencies, and, yes, even independent practice groups are exploring business strategies that will unite nephrologists under a common goal--that of an integrated renal delivery network. Nephrologists face what is probably their professional career's most important business decision: Partner with such organizations as hospitals, dialysis providers, or practice management companies, or form an independent nephrologist owned IPA and contract with an MSO. As nephrologists evaluate the options, they should seek partners that will at a minimum provide the following: a business plan that spells out the relationships of all the players; practice evaluations that can improved efficiencies; skilled day-to-day practice management; model legal documents; human resource management; expert, pro-physician reimbursement negotiation, coupled with a system to track contract profitability; case management, critical paths, practice guidelines; and renal industry expertise. Above all, nephrologists should seek partners in the formation of an integrated delivery system that offer an attitude dedicated to physician empowerment in the interest of good patient care

125.    McCullough, S. G., Kuhn, J. P., & Peskin, E. (1996). One HMO's experience with the management of hyperemesis gravidarum. Hmo Practice, 10(3), 143-5.

126.    Lynn, P. A. (1996). Relationship between total quality management, critical paths, and outcomes management. Seminars for Nurse Managers, 4(3), 163-7.
Abstract: Total quality management (TQM), clinical paths, and outcomes management are high-profile strategies in today's health care environment. Each strategy is distinct, yet there are interrelationships among them. TQM supports a customer-focused organizational culture, providing tools and techniques to identify and solve problems. Clinical paths are tools for enhancing patient care coordination and for identifying system-wide and patient population specific issues. Outcomes management is an integrated system for measuring the results in patient populations over time. There is a recent shift in outcomes measurement towards expanding both the nature of the outcomes examined and the timeframes in which they are studied

127.   Holmquist, M. (1996). Organ donor Care MAP: a multidisciplinary approach. [Review] [4 refs]. Journal of Transplant Coordination, 6(3), 101-4.
Abstract: A Care Multidisciplinary Action Plan was developed at a 300-bed rural medical center in 1994. Once a potential organ donor is identified and referred to the organ procurement organization and the family has consented to donation, the ICU nurse initiates the Care Multidisciplinary Action Plan, which is based on an 8-hour time frame for ICU care that may be adjusted as needed. The first hour includes prompts for coroner notification, billing changes, and completion of hospital-specific death notice forms. The remaining hours are spent administering tests and preparing the donor for organ retrieval. Collaborative issues such as donor family support also are addressed. ICU nurses who used the donor care Multidisciplinary Action Plan were interviewed to determine its effectiveness. [References: 4]

128.    Griffith, D., Hampton, D., Switzer, M., & Daniels, J. (1996). Facilitating the recovery of open heart surgery patients through quality improvement efforts and CareMAP implementation. American Journal of Critical Care, 5(5), 346-52.
Abstract: OBJECTIVE: To illustrate, using a literature review and CareMAPs, how care coordination and implementation of standard protocols can impact clinical outcomes for open heart surgery patients. METHODS: A CareMAP for open heart surgery patients was developed by a multidisciplinary team. To evaluate the effectiveness of CareMAP implementation and specific quality improvement efforts, a pilot study was done that focused on increasing activity levels, decreasing ventilator time, and decreasing the frequency of arterial blood gas sampling for a sample of 55 open heart surgery patients. A rapid recovery program was developed based on the results of this pilot study. A multidisciplinary continuous quality improvement team was developed to focus on three primary areas: ventilator weaning time, activity regimens, and early transfer to the open heart surgery step-down unit. Forty-nine open heart surgery patients were included in the initial program evaluation. RESULTS: The frequency of arterial blood gas sampling decreased from an average of 5.8 per patient to an average of 3.9 per patient. Postoperative length of stay also decreased by 1.3 days for diagnosis related group 106 patients, and 3.7 days for diagnosis related group 107 patients. Results of the pilot study demonstrated additional opportunities for improving the care of open heart surgery patients. Using the rapid recovery program, the average ventilator time decreased by 4.4 hours per patient. The average postoperative length of stay decreased to 4.7 days. CONCLUSIONS: Through the quality improvement process and through the use of CareMAPs and specific protocols, the recovery of open heart surgery patients was facilitated

129.    Gregor, C., Pope, S., Werry, D., & Dodek, P. (1996). Reduced length of stay and improved appropriateness of care with a clinical path for total knee or hip arthroplasty. Joint Commission Journal on Quality Improvement, 22(9), 617-28.
Abstract: BACKGROUND: In 1991 the orthopedics department at St Paul's Hospital, Vancouver, British Columbia, Canada, identified the clinical path as a way to shorten length of stay, improve efficiency of resource use, and minimize variation in care processes without compromising clinical outcomes for patients admitted for elective knee or hip arthroplasty. METHODS: A team of direct care providers collected baseline data for 77 patients to identify variables influencing length of stay (LOS) and variability in care processes. The team proposed an improved sequence of coordinated clinical decisions and treatments on a daily basis. The clinical path was disseminated by educating nursing and medical staff and by developing pre-printed orders and modifying the nursing care plan. RESULTS: Nine months after implementation of the clinical path, there was a statistically significant reduction in median LOS (12 to 9 days; p < 0.001), which was sustained for at least 18 additional months. Decreased use of inappropriate perioperative antibiotics and laboratory tests and no change in postoperative complications or readmission rate were also found. DISCUSSION: A new team is now developing a clinical path for hip fracture patients. In addition, other programs are using the template employed by the arthroplasty team to develop clinical paths for acute myocardial infarction, coronary artery bypass grafting, stroke, and drug overdose in the intensive care unit. SUMMARY: The team is now working toward a seven-day LOS for these patients. This experience has served as a model for development and implementation of other clinical paths for other groups of patients at the hospital

130.   Della-Latta, P. (1996). Clinical mycobacteriology. Work flow and optional protocols for laboratories in industrialized countries. [Review] [76 refs]. Clinics in Laboratory Medicine, 16(3), 677-95.
Abstract: The algorithm of the mycobacteriology laboratory of the 1990s relies heavily on growth-dependent procedures that are slow and labor intensive. The introduction of nucleic acid-based direct amplification tests portends future laboratories where molecular diagnostic assays will prevail. Financial constraints mandate an interdisciplinary approach to establish clinical pathways and rational tailoring of current protocols to curtail expensive overuse of dwindling resources. [References: 76]

131.    Cronin, A. L. (1996). Lung volume reduction surgery CareMap. A multidisciplinary approach to managing patient care. [Review] [5 refs]. Critical Care Nursing Clinics of North America, 8(3), 333-43.
Abstract: The introduction of Lung Volume Reduction Surgery (LVRS) presented an exciting challenge to the author's institution. A motivated, multidisciplinary collaborative group practice created the successful reality of the surgery. This was accomplished by formulating a realistic budget, providing essential staff education, and creating an LVRS CareMap. The CareMap provides critical direction for daily management of the patient and emphasizes integration of the patient and family into the continuum of care. The LVRS CareMap illustrates the vital importance of a fiscally sound plan of care that focuses on timely multidisciplinary interventions based on expected patient outcomes. [References: 5]

132.    Court-Tillis, D. (1996). Skin flap path incorporates 30-day LOS for rehabilitation. Hospital Case Management, 4(9), 135-8.

133.    Coleman, J. (1996). Supportive management of the patient with pancreatic cancer: role of the oncology nurse. Oncology, 10(9 Suppl), 23-5.
Abstract: The oncology nurse attends not only to the physiologic needs of the patient with pancreatic cancer but also to the educational, economic, logistic, and psychosocial factors that impact on quality of care. Managing patient care from admission through discharge in today's short hospitalization periods, the oncology nurse's vigilant attention to "patient care maps" helps keep the multidisciplinary healthcare team on schedule, contain costs, and maximize hospital resources. Patient and family education provided by the oncology nurse, along with take-home reference materials, facilitates adjustment to the cancer diagnosis, encourages patient compliance with treatment procedures and pain management, and can cut health-care costs by eliminating unnecessary post-discharge trips to the doctor's office or emergency room. Oncology nursing assists patients with pancreatic cancer along the continuum of care via whatever pathway is chosen

134.    Clare, M. W., Sargent, D., Ratzlaff, L., & Judd, J. (1996). Work redesign. Data analysis and clinical pathways pay off.  Strategies for Healthcare Excellence, 9(9), 8-12.

135.    Calligaro, K. D., Miller, P., Dougherty, M. J., Raviola, C. A., & DeLaurentis, D. A. (1996). Role of nursing personnel in implementing clinical pathways and decreasing hospital costs for major vascular surgery. Journal of Vascular Nursing, 14(3), 57-61.
Abstract: Collaboration with key nursing personnel is essential to successfully implement clinical pathways, establish a dedicated vascular wing, and achieve significant hospital cost savings while still maintaining quality care with low morbidity and mortality rates. Key nursing personnel met once a month during a 1-year period with vascular surgeons, hospital administrators, and health care advisors to plan strategies to develop clinical pathways and establish a dedicated vascular ward. The pathways were then implemented. We compared morbidity, mortality, readmission rates, adn hospital costs among two groups of patients admitted for major vascular surgery. Nursing personnel, attending staff, and surgical residents found that treating patients who had undergone major vascular surgery was more straightforward and efficient after clinical pathways and a dedicated vascular wing were established. In addition, there were no significant differences between the groups in terms of overall mortality or pulmonary, neurologic, or cardiac complications despite shorter hospital stay and decreased hospital costs. Also there were no significant differences in readmission rates within 30 days

136.    Burns, D. (1996). Appendix: collaborative pathway reports. Topics in Geriatric Rehabilitation, 12(1), 77-89.

137.    Appleby, C. (1996). Clinical paths. Prevention is the best medicine. Hospitals & Health Networks, 70(16), 40.

138.    Seay, R., O'Connell, M. B., & Peterson, M. (1996). Pharmacy involvement in and use of critical pathways in Minnesota hospitals. American Journal of Health-System Pharmacy, 53(16), 1950-2.

139.    Rough, S. S., Reid-Ganske, L. M., Thielke, T. S., & Ploetz, P. A. (1996). Work redesign and role restructuring in a pharmacy department with pharmacist assistants. American Journal of Health-System Pharmacy, 53(16), 1928-33.
Abstract: A new staffing model for decentralized pharmacists and support staff at a university hospital is described. A new technical support position--the pharmacist assistant--was created, and activities were reallocated among the pharmacists, pharmacist assistants, and pharmacy technicians according to the recommendations of two total quality management teams. Pharmacist assistants were to perform many of the drug distribution and record-keeping functions previously performed by pharmacists. The activities marked for reallocation accounted for about 50% of pharmacist time in the existing staffing model; they would not be performed by experienced pharmacy technicians who received brief training to be pharmacist assistants. Nine pharmacists and nine technicians tested the new staffing model on four patient care units over a four-week period. The reassignment of pharmacist tasks to pharmacist assistants theoretically gave pilot-unit pharmacists more time for providing and documenting patient-specific clinical activities and an additional 12 hours a week to participate in such global patient care activities as critical-pathway and quality improvement meetings. By the end of the study, the pharmacist assistants demonstrated that they could perform the reassigned activities; however, the pharmacists were not yet confident in the assistants' ability to do so. A pilot study of a new decentralized pharmacy staffing model demonstrated that technical support personnel can perform many distributive and record-keeping activities traditionally performed by decentralized pharmacists

140.   McIntosh, H. (1996). Memorial Sloan-Kettering goes electronic to manage patient care [news]. Journal of the National Cancer Institute, 88(15), 1024-6.

141.    Turley, K., Tyndall, M., Turley, K. M., Roge, C., Cooper, M., & Tarnoff, H. (1996). Cardiovascular-radical outcome method is effective in complex congenital cardiac lesions. Annals of Thoracic Surgery, 62(2), 386-91; discussion 391-2.
Abstract: BACKGROUND. The cardiovascular-radical outcome method is a proactive process of patient care that uses standard critical pathway methodology to reduce negative variation while encouraging positive variation to accelerate recovery. Its effectiveness in patients with complex congenital heart disease is explored. METHODS. Two hundred fourteen consecutive patients with congenital heart disease were cared for using the cardiovascular radical outcome method. Age ranged from 2 days to 19 years (median age, 3 years). Cardiovascular radical outcome method data were compared with the pathway plan data for each patient. RESULTS. Survival was 99% (211 patients) with an overall reduction in stay of 156 days (0.74 day/patient) (p < 0.0001). Only 10 patients (5%) exceeded the pathway plan; 201 (95%) reached the planned length of stay (critical pathway method), and 127 patients (60%) had a shorter length of stay than expected by the critical pathway method. One hundred forty-eight patients (70%), including 95 (64%) with more complex conditions, had a length of stay of 3 days and 18% achieved a 2-day length of stay, the maximal response. The process was most effective in the most complex groups, although preoperative comorbidities influenced outcomes. Outcome assessment demonstrated minimal morbidity and excellent family satisfaction. CONCLUSIONS. The radical outcome method is effective in reducing the length of stay of patients with complex congenital heart disease. The power is in the process rather than the plan, and the method provides optimal patient care and family satisfaction

142.    Stancliff, B. L. (1996). Careers. Making the individual count: individualized care vs. critical pathways. Ot Practice, 1(8), 13.

143.    Spath, P. (1996). Clinical paths: no smoking gun for malpractice cases. Help clinicians get over path anxiety. Hospital Peer Review, 21(8), 113-5.

144.    Smith, A. J. (1996). Chart reviews made simple. Nursing Management, 27(8), 33-4.
Abstract: Without a clear, organized approach, chart review can be disorganized and time consuming. A tool provides orderly, analytical and objective chart reviewing techniques.  (3 ref)

145.    Kitchiner, D., & Bundred, P. (1996). Integrated care pathways. [Review] [23 refs]. Archives of Disease in Childhood, 75(2), 166-8.

146.    Kayajan, T. (1996). Pathway automation: establishing a framework. QRC Advisor, 12(10), 1-8.

147.    Katz, S. G., & Kohl, R. D. (1996). Selective use of the intensive care unit after nonaortic arterial surgery. Journal of Vascular Surgery, 24(2), 235-9.
Abstract: PURPOSE: The purpose of this study was to determine whether the institution of a clinical protocol combining 6 hours of recovery room observation and guidelines for intensive care unit (ICU) admission would allow selected patients to be safely transferred directly to a surgical floor after nonaortic arterial reconstruction. METHODS: After a clinical pathway was formed, 134 consecutive patients undergoing 154 nonaortic arterial operations were prospectively enrolled in this study. Patients requiring ICU care and the responsible factors were identified. Comparisons of risk factors and demographics were made between those patients who did and did not require ICU care. RESULTS: Twelve (7.8%) patients spent a total of 27 days in the ICU (range 1 to 11 days). As per our guidelines four patients were transferred to the ICU for invasive monitoring, and four were sent to the ICU because of refractory hemodynamic instability or arrhythmia in the postanesthetic recovery room. An additional four patients were transferred to the ICU after having been on the surgical floor for 24 to 72 hours because of the following perioperative complications: prolonged chest pain (one), pneumonia (one), heart failure (one), and graft occlusion requiring a urokinase infusion. Patients admitted to the ICU were more likely to have heart disease (p = 0.02) and to have had an operation other than carotid endarterectomy (p = 0.04) than those who were not. The 30-day mortality rate was 1.4%. CONCLUSIONS: The implementation of a clinical protocol similar to the one used in this study will allow many patients undergoing nonaortic vascular surgery to avoid the use of the ICU. This approach will conserve hospital and financial resources without adversely affecting patient morbidity and mortality rates

148.    Jungkind, K., & Shaffer, R. (1996). CHF (congestive heart failure) path cuts length of stay, saves $2,300 per case. Hospital Case Management, 4(8), 119-22.

149.   Jones, S. G. (1996). Tuberculin testing in patients with human immunodeficiency virus/acquired immune deficiency syndrome. [Review] [33 refs]. AACN Clinical Issues, 7(3), 378-89.
Abstract: After declining for decades, the incidence of Mycobacterium tuberculosis is increasing. The Mantoux tuberculin skin test, which uses purified protein derivative (PPD) of tuberculin, has been used for years as a screening device to detect the presence of exposure and infection to tuberculosis. However, the advent of human immunodeficiency virus (HIV) has elicited many questions regarding the validity of traditional standards for PPD administration and interpretation. The uncertainties in interpreting tuberculin skin tests in immunocompromised individuals is part of the challenge that is being faced by the health-care profession in this 2nd decade of acquired immune deficiency syndrome. This article will help advanced practice nurses understand the relationship between the immune system, tuberculosis, and the PPD skin test; the problem of anergy with immunocompromised patients, particularly those who are HIV-infected; issues involved in placement and interpretation of the results of the PPD test; new Agency for Health Care Policy and Research (AHCPR) standards for PPD interpretation with HIV-infected persons; the "booster" effect and two-step PPD testing; concerns regarding bacille Calmette-Guerin vaccine; and the use of a critical pathway to aid in rapid identification and isolation of the patient with HIV admitted with a potential diagnosis of tuberculosis versus Pneumocystis carinii pneumonia. [References: 33]

150.    Ibarra, V., Titler, M. G., & Reiter, R. C. (1996). Issues in the development and implementation of clinical pathways. [Review] [18 refs]. AACN Clinical Issues, 7(3), 436-47.
Abstract: Issues related to the development and implementation of clinical pathways require thoughtful planning, collaborative teamwork, and an understanding of the evolutionary nature of this work. Creating an understanding of the purpose behind the development of these guidelines often is only the first issue to be considered. Other common issues include physician involvement, documentation, pathway development, variance data analysis and feedback, and integration with outcomes management activities. Successfully addressing these issues is an ongoing component of a clinical pathway program. [References: 18]

151.    Goldman, L. (1996). The JIM Interview. Lee Goldman, MD [interview]. Journal of Investigative Medicine, 44(6), 296-303.
Abstract: In early 1995, Lee Goldman, MD, left his post as chief medical officer at the Brigham and Women's Hospital in Boston to become the chairman of medicine at the University of California, San Francisco. A well-respected clinical epidemiologist, Goldman has been among the leading proponents of utilizing critical pathways to improve the efficiency of clinical care. His appointment as leader of a department steeped in a strong tradition of basic research was widely seen as another marker in the ascendancy of the field of health services research. However, in just his first year, Goldman has been active in working to further solidify his department's strong basic research foundation as well as expand its research scope, all in what many consider to be the most difficult and volatile of managed care markets. Interviewed on the wards of the UCSF medical center, Goldman reflected on the highly dynamic managed care environment of northern California, and the need to adapt medical training to the rules of a new era in health care

152.    Dennison, A. R., Kerrigan, D. D., Oakley, N., Paraskevopoulos, J. A., Peck, R., Collins, M. C., & Johnson, A. G. (1996). The role of the radiologist in surgical management: an audit of clinico-radiological conferences. Postgraduate Medical Journal, 72(850), 481-3.
Abstract: A prospective analysis of the radiological findings and final diagnoses of 342 patients discussed at joint surgical/radiological conferences over a seven-month period was undertaken in an attempt to define the role of the radiologist in the clinical management of surgical patients. Although the diagnosis had already been correctly made on clinical or radiological grounds in 38% (130/342) of patients presented at the X-ray conferences, careful review of the films resulted in an immediate firm diagnosis in a further 9% (31/342), or promoted further radiological investigations which were responsible for an eventual definitive diagnosis in 20% of the remainder (32/169). The input of the radiologist in selecting the most appropriate additional investigation was particularly valuable in the management of more complex clinical problems

153.    Chapman, B. (1996). Care pathways' 'pluses' adding up. CAP Today, 10(8), 1-12, 16, 20-22.

154.    Campbell, S. (1996). Accordant meets the challenges that rare chronic diseases pose for managed care. Health Care Strategic Management, 14(8), 18.

155.    Barr, J. E., & Cuzzell, J. (1996). Wound care clinical pathway: a conceptual model. Ostomy Wound Management, 42(7), 18-24, 26.
Abstract: A clinical pathway is a written sequence of clinical processes or events that guides a patient with a defined problem toward an expected outcome. Clinical pathways are tools to assist with the cost-effective management of clinical outcomes related to specific problems or disease processes. The primary obstacles to developing clinical pathways for wound care are the chronic natures of some wounds and the many variables that can delay healing. The pathway introduced in this article was modeled upon the three phases of tissue repair: inflammatory, proliferative, and maturation. This physiology-based model allows clinicians to identify and monitor outcomes based on observable and measurable clinical parameters. The pathway design, which also includes educational and behavioral outcomes, allows the clinician to individualize the expected timeframe for outcome achievement based on individual patient criteria and expert judgement. Integral to the pathway are the "4P's" which help standardize the clinical processes by wound type: Protocols, Policies, Procedures, and Patient education tools. Four categories into which variances are categorized based on the cause of the deviation from the norm are patient, process/system, practitioner, and planning/discharge. Additional research is warranted to support the value of this clinical pathway in the clinical arena

156.    Tahan, H. A. (1996). A ten-step process to develop case management plans. [Review] [16 refs]. Nursing Case Management, 1(3), 112-21.
Abstract: The use of case management plans has contained cost and improved quality of care successfully. However, the process of developing these plans remains a great challenge for healthcare executives. In this article, the author presents the answer to this challenge by discussing a 10-step format process that administrators of patient care services and case managers can adapt to their institutions. It also can be used by interdisciplinary team members as a practical guide to develop a specific case management plan. This process is applicable to any care setting (acute, ambulatory, long term, and home care), diagnosis, or procedure. It is particularly important for those organizations that currently do not have a deliberate and systematic process to develop case management plans and are struggling with how to improve the efficiency and productivity of interdisciplinary teams charged with developing case management plans. [References: 16]

157.    Spitzer, W. J. (1996). Reengineering integrated patient care at an academic medical center. Continuum (Chicago), 16(4), 10-5.

158.    Sobkowski, D. A., & Maquera, V. (1996). Critical path case management: the headache clinic. Best Practices & Benchmarking in Healthcare, 1(4), 198-202.
Abstract: A practical application of a neurology case management healthcare delivery mode results in increased access to specialty providers, shorter follow-up periods, and improved continuity of medical care. The program described in the following sections was developed at a naval hospital for the ongoing evaluation of therapeutic schemes to optimize headache therapy and, 1 year after implementation, shows improvement in patient outcomes and resource use

159.    Shamansky, S. L. (1996). Population-based managed care to improve outcomes. Nursing Economics, 14(4), 245-7.

160.    Richards, S. E. (1996). A closer look at case management. Journal for Healthcare Quality, 18(4), 8-11-quiz 11, 46.
Abstract: Healthcare organizations throughout the United States are attempting to find solutions to spiraling healthcare costs. Hospital administrators are questioning the cost-effectiveness of their care delivery models, while healthcare professionals are developing innovative measures to increase the cost-effective use of resources. This article explores hospital-based case management measures that are being used not only to control costs but also to de-escalate the continuously accelerating cost increases.  (Abstract by: Author)

161.    Meyer, L. C. (1996). Centers of excellence: a medical measurement or marketing myth? Medical Group Management Journal, 43(4), 66-68, 70 passim.
Abstract: Managed care organizations, physician groups and hospital systems are all increasingly pressured to identify new modes of treatment that produce verifiable outcomes while reducing the revolving door pattern of health care for the chronically ill. Providers are also faced with creating systems of care to differentiate themselves from the competition in the marketplace. Disease-specific health management programs are being used to address both issues. When used properly, they can be promising tools in the battle to maintain health care quality while containing costs. Skillful balancing of these two important factors can ensure maximum value for both patients and payers. Are centers of excellence the critical pathway of the future? Or are they merely a marketing ploy to generate incremental growth and profitability for savvy business executives and medical group management entrepreneurs? This article provides an overview of the center of excellence concept, addresses its misuse in the industry and discusses the strategic and marketing implications for organizations considering this approach as a tool to demonstrate full accountability and meritorious outcomes.  (Abstract by: Author)

162.    Kurec, A. (1996). An introduction to case management. Clinical Laboratory Management Review, 10(4), 346-56.
Abstract: Health-care professionals are constantly being challenged to find innovative ways to maintain quality of care with diminishing resources. Case management has emerged as a viable method of identifying resources and using those resources efficiently while providing the appropriate levels of care. The American Nurses Association defines case management as health assessment and planning, procurement, delivery, coordination, and monitoring to ensure that the multiple needs of the client are met. Organizations that have implemented case management report significant decreases in length of stay and substantial cost savings. The components of a successful case management team include a System Design Team to initiate the process, a Steering Committee to move the process forward, a Case Manager to coordinate and advocate for those patients who fall outside standard protocols or guidelines (critical pathways), an Interdisciplinary Specialty Team to assist in developing critical pathways, identifying variances, and evaluating data and outcomes, and an information system that provides accurate and current information. The :team: in case management team cannot be emphasized enough--medical staff and health-care providers should be involved in and understand case management practices. Collaboration and cooperation are essential to ensure patient satisfaction, hospital marketability, and presentation of a positive image to the community.  (Abstract by: Author)

163.    Kirk, J. K., Michael, K. A., Markowsky, S. J., Restino, M. R., & Zarowitz, B. J. (1996). Critical pathways: the time is here for pharmacist involvement. American College of Clinical Pharmacy. Pharmacotherapy, 16(4), 723-33.
Abstract: Successful development, implementation, and assessment of the effectiveness of critical pathways involves many processes and tools. Numerous pathways have been developed and the value of this tool in improving patient care has been demonstrated in some patient groups.27,29 Pharmacists are becoming more involved, but the window of opportunity is small. Critical pathways are routinely being utilized to optimally sequence time-appropriate interventions of the interdisciplinary plan of care set forth to achieve patient satisfaction and desired outcomes. Pharmacists must seize the chance to provide pharmaceutical care and assure their participation in the development and implementation of critical pathways

164.    Kanter, P. M., & Otwell, J. A. (1996). Diabetes case management: exploring staff practice patterns. Diabetes Educator, 22(4), 333, 335-336, 339.

165.    Guthrie, S. (1996). Patient pathways for extracorporeal shock wave lithotripsy. Nursing Case Management, 1(3), 122-4.

166.    Favor, G., & Ricks, R. (1996). Preparing to automate the case management process. [Review] [6 refs]. Nursing Case Management, 1(3), 100-6.
Abstract: In this article, the authors discuss case management automation and the preparation that an organization should be making to install such a system successfully. They begin with a discussion of the goals of case management automation, and then review the steps that all facilities with case management programs can undertake to standardize their process, structure their organization, and strategically plan for case management automation. The current status of case management automation efforts also is discussed. The authors conclude by describing the efforts of one organization to develop an integrated case management documentation system. [References: 6]

167.    Edwards, D., & Hess, L. (1996). Aggressive weaning in cardiac surgical patients. [Review] [11 refs]. Dimensions of Critical Care Nursing, 15(4), 181-6.
Abstract: Nursing management of cardiac surgical patients has changed dramatically over the last several years. The need for cost-effective care with quality patient outcomes has forced critical care nurses to re-evaluate the standard of practice for postoperative cardiac patients. The authors describe the implementation of a fast-track weaning program giving critical care nurses more responsibility for weaning decisions and choice of sedative agent. Our experience in a six-bed Cardiothoracic Recovery Unit (CRU) in a midwestern community hospital evolved from receiving heavily anesthetized patients, continuing sedation postoperatively and prolonged intubation to minimal pharmacologic intervention with propofol and early extubation. In the fast-track weaning protocol, the nurses were given more authority to make critical decisions during the weaning process. This article describes the transition from the traditional time-based weaning system to the fast-track system where individual weaning progress is monitored by the critical care nurses. [References: 11]

168.    Czarnecki, M. (1996). Using benchmarking in the hospital environment: a case study. Best Practices & Benchmarking in Healthcare: a Practical Journal for Clinical & Management Applications.   1(4), 221-224.
Abstract: As the industry becomes more competitive, many hospitals and other healthcare companies are turning to benchmarking to help them make appropriate changes to their organizations. Benchmarking allows companies to identify "best practices" and make process comparisons with other organizations. The University of Cincinnati Hospital is one example of a hospital that has effectively used benchmarking for process improvement

169.    Cesta, T. G., Fink, L., & Hogan, P. L. (1996). Case management plans and their application to maternal-child health. [Review] [9 refs]. Nursing Case Management, 1(3), 138-51.
Abstract: The implementation of case management plans in the maternal-child health environment is quickly escalating as the managed care industry infiltrates the country. Most institutions began their initiatives in the medical-surgical arena, where length of stay and cost reduction opportunities pose the greatest challenges but also the greatest opportunities. However, recent case management focus in pediatrics and neonatal intensive care units have demonstrated successful results. [References: 9]

170.    Behr, C., Mercier, C., & Schriefer, J. (1996). Strategies for involving physicians in continuous quality improvement. Journal for Healthcare Quality, 18(4), 21-3.
Abstract: To realize significant and sustained improvement in quality and in overall performance, hospitals must have the support and participation of the medical staff. Although it sometimes is difficult to recruit busy physicians to join the effort, they will become champions if their experience is productive and results in improved patient care. This article outlines a number of straightforward approaches that will help healthcare quality professionals obtain physician involvement in the improvement effort.  (Abstract by: Author)

171.    Welsh, C., & McCafferty, M. (1996). Congestive heart failure: a continuum of care. Journal of Nursing Care Quality, 10(4), 24-32.
Abstract: Congestive heart failure is the nation's most rapidly growing category of cardiovascular disorders. As more and more people are surviving cardiac insults, health care providers are called upon to improve the health status of this population. The article describes a program at Advocate Health Care that follows the patient beyond the four walls of the hospital after discharge and into the most appropriate care environment for him or her. The evolution of a clinical quality improvement project aimed at partnering with patients in the care of this chronic illness is discussed

172.    Rosen, L. S., Schroeder, K., Hagan, M., Acord-Szczesny, J., & Garavaglia, M. (1996). Adapting a statewide patient database for comparative analysis and quality improvement. Joint Commission Journal on Quality Improvement, 22(7), 468-81.
Abstract: BACKGROUND: In 1991 the Michigan Health and Hospital Association established the Michigan Patient Outcome Measures Program to support quality improvement activities among member hospitals. Data submitted by each hospital are based on the Uniform Hospital Discharge Data Set (UHDDS). REPORTING THE MEASURES: Each participating hospital is provided with tabulations for each of the 18 indicators, along with comparative data for each of five hospital peer groups. CASE STUDY 1: FACILITATING DEVELOPMENT OF A CLINICAL PATHWAY: Review of data on stroke patients indicated that patients discharged to home represented the single largest group of patients and that their length of stay was lower than for other groups of stroke patients. Hospital A used a clinical pathway to achieve reduction in length of stay of almost a day for this group. CASE STUDY 2: IMPROVING OBSTETRICS AND GYNECOLOGIC SERVICES THROUGH EDUCATION: The Department of Obstetrics and Gynecological Surgery at Hospital B achieved improvement in birth trauma, hysterectomy, cesarean section (C-section) births, and vaginal births after C-section. Program participants are considering adopting a birth trauma indicator. CASE STUDY 3: ESTABLISHING A HOSPITALWIDE QI PROGRAM: The Newborn Team at Hospital C initiated several QI initiatives aimed at reducing the newborn mortality rate, including guidelines for earlier identification of high-risk obstetric cases and for earlier intervention by the perinatalogist. CONCLUSIONS: Data that are not risk or severity adjusted have value in assessing hospital procedures and systems and can be used to educate and effect change in practice patterns

173.    Johnson, S., & Burall, K. (1996). Pathway to the heart. Nursing Management, 3(4), 24-5.

174.    Enlow, M. L. (1996). Drug-usage evaluation by disease state: developing protocols. Pharmacy Practice Management Quarterly, 16(2), 18-25.
Abstract: The Joint Commission definition of drug-usage evaluation (DUE) also applies to DUE by disease state. The criteria for disease process selection, key processes being evaluated, methods to develop initial DUE protocols, and DUE validation and approval processes are reviewed. The treatment of community-acquired pneumonia is a disease state DUE performed at Saint Joseph Health Center in Kansas City, Missouri. The preliminary protocol was developed by a collaborative network of clinical pharmacists in the metropolitan area. Outcome measures were included in the evaluation. The results were used as baseline data in the development of a pneumonia clinical pathway.  (Abstract by: Author)

175.    Bray, J. (1996). Hip path helps caregivers identify patient learning needs. Hospital Case Management, 4(7), 103-6.

176.    Brailer, D. J., Goldfarb, S., Horgan, M., Katz, F., Paulus, R. A., & Zakrewski, K. (1996). Improving performance with clinical decision support. Joint Commission Journal on Quality Improvement, 22(7), 443-56.
Abstract: BACKGROUND: CADU/CIS (Clinical and Administrative Decision-support Utility and Clinical Information System) is a clinical decision-support workstation that allows large volumes of clinical information systems data to be analyzed in a timely and user-friendly fashion. CARE PROCESS MEASUREMENT: For any given disease, subgroups of patients are identified, and automated, customized "clinical pathways" are generated. For each subgroup, the best practice norms for use of test and therapies are identified. Practice style variations are then compared to outcomes to focus inquiry on decisions that significantly affect outcomes. CASE STUDY: INTESTINAL OBSTRUCTION: Graduate Health Systems, a multisite integrated provider in the Philadelphia area, has used CADU/CIS to improve quality problems, reduce treatment-intensity variations, and improve clinical participation in care process evaluation and decision making. A task force selected intestinal obstruction without hernia as its first study because of the related high-volume and high-morbidity complications. Use of a ten-step method for clinical performance improvement showed that the intravenous administration of unnecessary fluids to 104 patients with intestinal obstruction induced congestive heart failure (CHF) in 5 patients. Task force members and other practicing physicians are now developing guidelines and other interventions aimed at fluid use. Indeed, the task force used CADU/CIS to identify an additional 250 patients in one year whose conditions were complicated by CHF. CONCLUSION: A clinical decision support tool can be instrumental in detecting problems with important clinical and economic implications, identifying their important underlying causes, tracking the associated tests and therapies, and monitoring interventions

177.    Wigfield, A., & Boon, E. (1996). Critical care pathway development: the way forward. British Journal of Nursing, 5(12), 732-5.
Abstract: In many NHS trusts throughout the UK, critical pathways are being used as a method of managing patient care, enabling trusts to ensure that patients receive appropriate, high quality, cost-effective care. At the same time they can meet some of the requirements of The Patient's Charter, such as involving patients in decision making and keeping them informed during periods of treatment. This article first describes critical pathways and then discusses briefly the reasons why pathways were developed at the Guy's and St Thomas' Trust, and the stages of development before their introduction

178.    Wigfield, A., & Boon, E. (1996). Clinical. Critical care pathway development: the way forward. British Journal of Nursing, 5(12), 732-5.
Abstract: In many NHS trusts throughout the UK, critical pathways are being used as a method of managing patient care, enabling trusts to ensure that patients receive appropriate, high quality, cost-effective care. At the same time they can meet some of the requirements of The Patient's Charter, such as involving patients in decision making and keeping them informed during periods of treatment. This article first describes critical pathways and then discusses briefly the reasons why pathways were developed at the Guy's and St Thomas' Trust, and the stages of development before their introduction.  (5 ref)

179.    Roome, D. R. (1996). Spotlight. Clinical maps point way to quality at Saddleback. Nurseweek (California Statewide Edition), 9(13), 2.

180.    Udpa, S. (1996). Activity-based costing for hospitals. Health Care Management Review, 21(3), 83-96.

181.    Rask, K. J., Hayes, R. P., Becker, E. R., & Ballard, D. J. (1996). Emory University Center for Clinical Evaluation Sciences: a model for clinical practice evaluation in the changing environment of the academic health center. Quality Management in Health Care, 4(4), 47-54.
Abstract: Changes in the health care marketplace have had a profound effect on academic health centers and their traditional missions: teaching, patient care, and research. Many academic health centers have recognized the need to develop a capability for evaluating clinical practices and organizational restructuring. The Center for Clinical Evaluation Sciences at Emory University represents a model for the integration of evaluative capabilities into academic clinical practices.  (Abstract by: Author)

182.    Priesmeyer, H. R., Sharp, L. F., Wammack, L., & Mabrey, J. D. (1996). Chaos theory and clinical pathways: a practical application. Quality Management in Health Care, 4(4), 63-72.
Abstract: Nonlinear analysis can improve the adaptive ability of clinical paths and aid in providing improved continuity of care. This article continues our exploration of the ways "chaos theory" can be applied in health care by focusing on clinical applications. It describes a specific application of nonlinear techniques to knee arthroplasty, but the generalized nature of the technique suggests it can be applied in many other settings. The approach offers an innovative means for both improved patient care and cost savings.  (Abstract by: Author)

183.    Love, M., & Khanna, R. (1996). Home health care, managed care, and capitation. Healthcare Information Management, 10(2), 57-60.

184.    Hoxie, L. O. (1996). Outcomes measurement and clinical pathways. JPO:  Journal of Prosthetics & Orthotics, 8 (3), 93-5, 20A-21A.
Abstract: In the evolution of quality assessment activities within the healthcare field, outcomes measurement has become the principal objective for demonstrating optimal care. Clinical pathways increasingly are being used as the methodology of choice to achieve acceptable outcomes. This article briefly describes outcomes and clinical pathways. It also suggests a practical, step-by-step approach for O&P facilities to use in the development of such pathways for orthotics and/or prosthetics patients. This approach will facilitate the impact that each provider and setting of service has on the patient's outcome. Finally, an abbreviated bibliography is provided as a resource for further reading.  (3 ref 6 bib)

185.    Wilkerson, G. (1996). Functional rehabilitation. A protocol for management of the lateral ankle sprain. Rehab Management, 9(4), 54-60.

186.    Williams, S. C. (1996). Case studies in nursing management. Outcome-based practice: convince me!... including commentary by Somerville JG. Seminars for Nurse Managers, 4(2), 84-7.

187.    White, R. B. (1996). Epoetin alfa--focus on nursing case management. Case study of the anemic patient. Anna Journal, 23(3), 326-9.
Abstract: Case management is a multidisciplinary collaborative approach that emphasizes continuity of patient care. Nursing case management can lead to improvements in the quality of care while affording nurses the opportunity to increase their expertise, autonomy, and authority in the health care system. Treatment of the anemia of end-stage renal disease (ESRD) is used as an example to illustrate the implementation of these principles in the dialysis unit

188.    Wentworth, D. A., & Atkinson, R. P. (1996). Implementation of an acute stroke program decreases hospitalization costs and length of stay. Stroke, 27(6), 1040-3.
Abstract: BACKGROUND AND PURPOSE: A large community hospital implemented an acute stroke program to respond to stroke patients in a consistent, systematic, and efficient manner. The primary objectives were to monitor the care delivered, improve the quality of care, and move the patients through their initial hospital stay in a timely manner. METHODS: Acute stroke standing orders were developed, with a critical path developed on the basis of these orders and an expected length of stay. A multidisciplinary team began the rehabilitation process early in the hospital stay, monitored patient progress and length of stay, and provided appropriate discharge placement. Retrospective chart reviews were performed over a 4-year period, and the data were collated on a yearly basis. RESULTS: Over a 4-year period, 414 Medicare patients demonstrated a steady decline of initial hospital length of stay from 7.0 to 4.6 days. During this same period of time, there was a decline in total hospital charges from $14,076 to $10,740 per patient. This represented a total dollar savings in charges of $1,621,296 (approximately $453,000 per year). The mortality rate for 1994 was 4.6%, with 46.5% of survivors discharged to home, 16.9% to acute rehabilitation, and 32.6% to nursing homes. CONCLUSIONS: The implementation of a multidisciplinary acute stroke program decreased length of stay and hospitalization costs of Medicare patients

189.    Vecchi, C. J., Vasquez, L., Radin, T., & Johnson, P. (1996). Neonatal individualized predictive pathway (NIPP): a discharge planning tool for parents. Neonatal Network, 15(4), 7-13.
Abstract: The development of clinical pathways has paralleled the national movement to control health care dollars. This movement is particularly intense in states with extensive managed care plans, such as Arizona. Early infant discharge with minimal home nursing support is a reality that forces parents to anticipate their discharge needs well in advance of the actual discharge date. The 59-bed NICU at Phoenix Children's Hospital uses neonatal individualized predictive pathways (NIPPs) as a discharge planning tool with parents of premature infants less than 32-weeks gestation. The NIPPs were developed after an extensive retrospective record review identified time frames for a variety of medical therapies and clinical milestones. Parent and nursing staff expectations are specified on a weekly basis opposite the medical therapies. This article discusses the positive parental response to the NIPP and identifies future areas for development

190.    Van Dyck, L., Maturen, V., & Gahn, G. (1996). Outcome-based critical pathways: quality management. Caring, 15(6), 30-7.

191.    Swett, E. (1996). Rehab resource. Home care aides improve costs, outcomes, and satisfaction. Caring, 15(6), 52-5.

192.    Stancliff, B. L. (1996). Careers. Clear communication is one key to success. Ot Practice, 1(6), 15,17,21.

193.    Spath, P. L. (1996). VHA (Veterans Health Administration) looks at clinical practice guidelines, pathways, and algorithms. Journal of Ahima, 67(6), 44-6.

194.    Somerville, J. G. (1996). Outcome-based practice: convince me. Seminars for Nurse Managers, 4(2), 84-5; discussion 86-7.

195.    Schriefer, J., Cali, R., Sugiyama, G., & Ryan, D. L. (1996). Focus on quality. Linking process improvement, critical paths, and outcome data to increased profitability. Surgical Services Management, 2(6), 46-50.

196.    Schaffer, C., & Srp, F. (1996). Outcome-driven home care: quality, savings, and results. Caring, 15(6), 8-11-2.

197.    Papa, A. (1996). Coordinated care guides detail arteriogram outcomes. Hospital Case Management, 4(6), 87-90.

198.    Morgan, T., Kofoed, L., & Petersen, D. B. (1996). Clinical pathway effects on treatment of the alcohol withdrawal syndrome. South Dakota Journal of Medicine, 49(6), 195-200.
Abstract: We investigated whether initiating a clinical pathway, that incorporated the use of an alcohol withdrawal assessment scale, would decrease length of stay (LOS) for and/or amount of benzodiazepine prescribed during uncomplicated alcohol detoxification. We retrospectively reviewed alcohol detoxification admissions on an inpatient unit: 66 admissions before, 56 after, and 75 admissions 1-year after initiation of the pathway. Admissions were grouped into completers and non-completers. Comparison of group means before and after pathway implementation demonstrated a significant decrease in LOS for completers of the detoxification service from 7.35 to 4.77 days, and from 6.67 to 4.31 days for all admissions. Similarly, total benzodiazepine exposure decreased to a third of the mg amount given per admission prior to the pathway. There were no increases in the "irregular" discharge rate or complication rate. These findings suggest that a clinical pathway, with an incorporated withdrawal assessment scale, can decrease LOS and benzodiazepine prescribing on an alcohol detoxification unit

199.    Martin, S. A. (1996). Assessing and caring for the infant liver transplant recipient. [Review] [25 refs]. Critical Care Nurse, 16(3), 74, 79-88.

200.    Lee, S. S. (1996). Hospital-home care critical pathways in disease management: improving case management and patient outcomes in postoperative cardiothoracic surgical patients. Journal of Care Management, 2(3), 42,46-46,50 passim.
Abstract: Efforts to reduce hospital lengths of stay have created both havoc and new opportunities for case managers and providers. They can develop and implement disease-specific critical pathways that begin in the hospital and end when all patient needs are met, including posthospitalization needs in the home. When coordination of care results in a seamless continuum, the benefits may include improved care, reduced length of stay, maximization of alternate care, and cost reduction. This article describes the development and implementation of a model for a hospital-home care continuous critical pathway for postoperative cardiothoracic surgical patients

201.    Lau, C., Cartmill, T., & Leveaux, V. (1996). Managing and understanding variances in clinical path methodology: a case study. Journal of Quality in Clinical Practice, 16(2), 109-17.
Abstract: Clinical path is a tool to improve efficiency. The increasing use of this methodology is evidenced by the proliferation of literature documenting its usage. A search of Cumulative Index to Nursing & Allied Health Literature (CINAHL) alone yielded over 38 articles related to clinical path. This trend of using clinical path to manage patient care is also evident from the recent literature in Australia. However, the literature has been silent on the documentation, interpretation and management of the variances. The purpose of this paper is to describe our three years' experience with clinical path management. Some examples of the variances we have experienced in the cardiac unit will be discussed

202.    Greengold, N. L., & Weingarten, S. R. (1996). Developing evidence-based practice guidelines and pathways: the experience at the local hospital level. Joint Commission Journal on Quality Improvement, 22(6), 391-402.
Abstract: BACKGROUND: Using an evidence-based approach to developing clinical practice guidelines at the local level promotes implementation by clinicians. In 1994 Cedars-Sinai Health System embarked on a joint project with VHA, Inc, to pilot test a software program, Clinical Cost-Reduction System (CCRS), featuring length-of-stay guidelines for low-risk patients with specific conditions. Data currently are being collected on the effect of the software on length-of-stay reductions and other important patient outcomes. THE NEED FOR A MORE COMPREHENSIVE SOFTWARE PROGRAM: To involve clinicians more actively in the development of guidelines, Cedars-Sinai sought to develop a software system for presenting organized medical information to hospitals interested in designing their own evidence-based clinical pathways. DEVELOPING THE CLINICAL PATHWAY CONSTRUCTOR (CPC): The CPC is a computerized grid for writing clinical pathways, backed by a database of information for select clinical conditions and categories of care. Multidisciplinary teams are to review the evidence presented in the database and then determine those guidelines they wish to encode into an actual pathway, which can then be printed out. The decision regarding which guidelines to use and which not to use rests entirely with the team designing a pathway; the program is intended to aid the team in developing appropriate guidelines that are evidence based, not to legislate guidelines. Data on the "portability" of the program are still being collected. SEARCHING AND SUMMARIZING THE LITERATURE: There are many challenges involved in searching, summarizing, and classifying the medical literature

203.    Gainer, F. E. (1996). Developing a clinical pathway for stroke. Ot Practice, 1(6), 30-3.
Abstract: A Washington, DC, hospital wanted to decrease the length of time that its patients with stroke spent in acute care. Frank E. Gainer outlines the multidisciplinary plan that allowed that goal to be met.  (2 ref)

204.    Ellenberg, D. B. (1996). Outcomes research: the history, debate, and implications for the field of occupational therapy. American Journal of Occupational Therapy, 50(6), 435-41.
Abstract: The field of occupational therapy, as with all facets of health care, has been profoundly affected by the changing climate of health care delivery. The combination of cost-ectiveness and quality of care has become the benchmark for and consequent drive behind the rise of managed health care delivery systems. The spawning of outcomes research is in direct response to the need for comparative databases to provide results of effectiveness in health care treatment protocols, evaluations of health-related quality of life, and cost containment measures. Outcomes management is the application of outcomes research data by all levels of health care providers. The challenges facing occupational therapists include proving our value in an economic trend of downsizing, competing within the medical profession, developing and affiliating with new payer sources, and reengineering our careers to meet the needs of the new, nontraditional health care marketplace.  (28 ref)

205.    Duggan, J. M. (1996). Clinical pathways and guidelines [editorial]. Journal of Quality in Clinical Practice, 16(2), 67-8.

206.    Dancer, S. (1996). Redesigning care for the nonhemorrhagic stroke patient. Journal of Neuroscience Nursing, 28(3), 183-9.
Abstract: Stroke patients, with their wide variety of needs, pose a complex care challenge to the health care provider. Trajectories of the patient's experience with the entire episode of illness, as well as ideal outcomes were used to redesign care for stroke patients. A multidisciplinary team including patients, pastoral care, social work, physicians, rehabilitation services and home health nurses designed a process to insure continuity of care across settings. Critical paths, discharge instructions and other tools were designed to facilitate care coordination within the acute phase of illness. Goals were to improve patient and team satisfaction, improve resource utilization and facilitate coordinated patient progress through the health care system. While this process was used to improve care of the stroke patient, the designed template can be used to direct redesign efforts for other selected patient populations as well

207.    Cunningham, J. (1996). Michigan hospital tests four outpatient clinical pathways. Inside Ambulatory Care, 3(3), 1,4.
Abstract: Hypertension and diabetes care standardized

208.    Burek, C., Collins, N. A., & Hodlin, A. (1996). An easy way to communicate pathways to patients. Hospital Food & Nutrition Focus, 12(10), 4; suppl 1 p.

209.    Briody, H. T. (1996). Improving midwifery practice through clinical pathways. Journal - Australian College of Midwives, 9(2), 11-3.

210.    Baruth, P., & Best, R. (1996). Mapping the care of patients who have an ostomy... originally presented at the CAET Conference in Nov 1995. Caet Journal, 15(2), 15-7.

211.   Moody, L., Rowland, K., Fairlough, F., & Al-Khoffash, M. (1996). Stroke care. Different strokes. Health Service Journal, 106(5502), 26-7.

212.    Morrissey, J. (1996). VHA reaches marketing accord on pathways software [news]. Modern Healthcare, 26(19), 30.

213.    Williams, M. (1996). Three alternative methods of developing critical pathways cost and benefits. Best Practices & Benchmarking in Healthcare, 1(3), 126-8.
Abstract: Three common methods of determining optimum pathways and their attendant cost and time requirements will be evaluated. Popular methods used for the development and adaptation of pathways are the use of published guidelines, the creation of pathways within an existing health care system and the use of an automated tool. The cost and time required for each of these methods vary tremendously

214.    Smeltzer, C. H., & Baler, A. J. (1996). Formula for the future: the elements of successful case management. Michigan Health & Hospitals, 32(3), 20-2.

215.    Perez, C. (1996). The next frontier in clinical pathways. The journey to outcomes management. Nursing Case Management, 1(2), 75-8.
Abstract: The Children's Memorial Hospital, a 265-bed pediatric hospital in Chicago, Illinois, is a leader in pediatric clinical pathway development. Significant improvements in care coordination and cost savings have been realized from the 14 pathways implemented to date. Use of a project management methodology and adaptation of continuous quality improvement tools for pathway development have proven effective to streamline and standardize this process. Despite its success in pathway development, Children's Memorial Hospital has realized the need to go further. It is necessary to measure outcomes--real clinical, patient outcomes--not just financial or utilization outcomes. Solid comparative data from which practice changes can be made are needed. Additional ways must be found to facilitate movement along the care continuum. Pathways must be used consistently. This article will outline the process Children's Memorial Hospital used and share the development tools that have been implemented. Children's Memorial Hospital's vision for the future and the technology designed to realize that vision are delineated

216.    Parker, C. D. (1996). Computer spreadsheets: an effective way to manage, analyze, and present quality indicators. [Review] [1 refs]. Nursing Case Management, 1(2), 62-3.

217.    Morris, M., Jameson, S., Murdock, S., & Hohn, D. C. (1996). Development of an outcomes management program at an academic medical center. Best Practices & Benchmarking in Healthcare, 1(3), 118-25.
Abstract: BACKGROUND: With the advent of managed care, academic medical centers have been challenged to lower costs and to document their claims of high quality outcomes. A successful method to achieve these objectives must not interfere with the academic missions of research and teaching. At M. D. Anderson Cancer Center, we initiated a program that would reduce practice variability and increase quality with a model that was familiar to the faculty. METHODS: Professional staff members were divided into disease site groups that included physicians, nurses, and other allied health staff. Each group developed practice guidelines and Collaborative Care Paths, based on evidence in the publications and on expert opinion. Desired outcomes were prospectively defined during this process. Before implementation, paths and guidelines underwent peer review. RESULTS: The faculty actively participated in the development and implementation of the program that was viewed as a means of empowerment to deal with managed care. Nearly 1000 patients have been entered on the B8 paths that have been implemented to date. CONCLUSION: A physician-driven outcomes management program permits delivery of high quality care and supports outcomes research while decreasing cost in an academic setting

218.    Mazur, L., Miller, J., Fox, L., & Howland, R. (1996). Variation in the process of pediatric asthma care. Journal for Healthcare Quality, 18(3), 11-7.
Abstract: In May 1994, the continuous quality improvement team at Hermann Children's Hospital in Houston, TX, began to study the structure, process, and outcome of asthma care for pediatric patients. The team's immediate goals were to identify variation in the treatment of pediatric asthma and to determine the most cost-effective interventions. This article details the team's development of a clinical pathway to reduce variation in patient care; use of the pathway led to a reduction in length of stay and a corresponding reduction in costs.  (Abstract by: Author)

219.    Locke, D. (1996). Filling the gap. Queensland Nurse, 15(3), 24-5.

220.    Lareau, S. C., Breslin, E. H., & Meek, P. M. (1996). Functional status instruments: outcome measure in the evaluation of patients with chronic obstructive pulmonary disease. [Review] [63 refs]. Heart & Lung, 25(3), 212-24.
Abstract: The purpose of this article is to review the instruments developed to measure functional status in patients with chronic obstructive pulmonary disease. Because the ability to carry out day-to-day activities is of primary importance to patients with chronic obstructive pulmonary disease, it is necessary for clinicians to understand which instruments provide the best measures of patient activity levels. Furthermore, as a critical outcome in managed care services, pulmonary critical pathways, and patient disability, the measurement of functional status in clinical practice assumes greater relevance. Functional status instruments in this review will refer to questionnaires measuring the day-to-day activities of patients. Questionnaires reviewed will include those that provide measures of general health status with activity-specific items, as well as questionnaires specifically designed to evaluate patients with pulmonary disease. The psychometric strengths, reliability and validity, and clinical utility of the instruments will be presented. [References: 63]

221.    Kowal, N. S., & Delaney, M. (1996). The economics of a nurse-developed critical pathway. Nursing Economics, 14(3), 156-6.
Abstract: During this study the use of a nurse-developed, patient-oriented critical pathway and its effects on two indicators of cost were analyzed at St. John Hospital and Medical Center in Detroit, Michigan. Financial data for 64 mastectomy cases were tracked and analyzed. Findings showed improved length of stay with substantial decreases in cost per case

222.    Hunter, J., & Roberts, F. (1996). A clinical path in an acute care hospital [letter]. Best Practices & Benchmarking in Healthcare, 1(3), 167-8.

223.    Holt-Turner, I., Nadel, S., McCarthy, S. M., Menasse-Palmer, L., & Cupoli, J. M. (1996). Children with special health care needs: clinical pathways. Continuum (Chicago), 16(3), 14-20.

224.    Gibbs, B., & Lonowski, L. (1996). Strategies for decreasing documentation: an example in maternal child health. Nursing Case Management, 1(2), 79-82.

225.    Frommer, A. G. (1996). Benchmarking, monitoring and moving through the continuum of the clinical pathway system. Best Practices & Benchmarking in Healthcare, 1(3), 157-60.

226.    Day, C. (1996). The evolution of case management. One organization's experience. Nursing Case Management, 1(2), 54-8.
Abstract: The case management program at Stanford Health Services has evolved over the past 5 years in response to the changing managed care marketplace and institutional needs. The challenge for the program has been to meet rapidly changing needs of both internal and external customers: patients, physicians, staff, and payers. The program has evolved from an inpatient model integrating discharge planning and utilization review, to include ambulatory case management in the clinic setting, management of prepaid health enrollees in the community, and clinical pathways. This article will describe the evolution of case management at Stanford and individual program components that resulted in significant savings to the organization

227.    Barnette, J. E., & Clendenen, F. (1996). Making the transition to critical pathways--a community behavioral health center's approach. Best Practices & Benchmarking in Healthcare, 1(3), 147-56.
Abstract: BACKGROUND: Shawnee Hills, Inc., formally began the transition to critical pathways in January 1996. The goal was to design and implement a service delivery model with clearly defined clinical paths and appropriate and functional technical support systems. No specific goal date for full implementation was designated; however, the intent was to move into the new system in a manner that allowed both consumer and employee participation in the planning process and to accommodate the organization's transition from a fee-for-service to a capitated model of contracting for services. The target date for completion of phase one, research and initial planning, was March 1, 1996. Although there were a number of benefits anticipated in adopting the critical paths method (CPM), the primary rationale was threefold: (1) standardizing the quality of care and treatment, (2) cost containment, and (3) better positioning of the organization for success within a capitated funding environment. A review of the publications indicated that the CPM had proved to be effective in other healthcare fields. In addition, the goals and approaches inherent within the CPM were consistent with the organization's total quality management (TQM) philosophy and operational practices. METHOD: By using the approach common to the organization since the adoption of the principles and practices of TQM in early 1992, a team was appointed with the mission of reengineering the clinical services delivery model. Unlike previous instances, however, this team was comprised largely of senior leadership, and two staff members were assigned on a full-time basis. A more detailed review of publications was conducted and, where possible, identification of critical pathways developed within the mental health field in other states were secured. Focus groups were used to address "best" or "preferred" practices for specific populations and age groups. Team members provided an orientation to the process, along with the opportunity to critique proposed pathways and models for service delivery as they were drafted to all employees through participation in ongoing staff development efforts. The center leadership was kept informed and was provided additional opportunities for input through regular presentations to the Quality Council that meets on a weekly basis. RESULTS: The first phase of the transition, research and initial planning, was completed on March 1, 1996. To date, the team has adopted or developed initial drafts of proposed clinical pathways for frequently occurring diagnoses within adult and child mental health, adult and child substance abuse, and specific to early childhood for the mental retarded or developmentally delayed. A model for clinical pathways was developed incorporating the JCAHO requirements to address assessment, care, and education at the major junctures of service delivery. In addition, the team formulated recommendations specific to priority areas for each major pathway and the approach to be taken in the transition from a fee-for-service to a capitated environment. A service delivery model built around acute care and continuing care was outlined, but remains a work-in-progress at this time. Finalizing the model and the completion of the clinical pathways for specific diagnostic groupings are two priorities for the second phase, product development-continued planning and transition, now underway. CONCLUSIONS: Although the effort is very much outcomes-oriented, data are not available at this early stage in the process. (ABSTRACT TRUNCATED)

228.    Weber, D. O. (1996). Case study. Aggressive physician-led clinical reengineering helps University of California-San Francisco Medical Center stay competitive. Strategies for Healthcare Excellence, 9(5), 1-10.

229.    Thompson, D., Graham, M. J., & Klava, K. (1996). Subacute providers measure success. Provider, 22(5), 41-2-44.

230.    Schneider, P. (1996). Consult an expert: your computer. Healthcare Informatics, 13(5), 37-8-40, 42.

231.    Poole, J., Stevenson, D., & George, J. (1996). A high-involvement health care model. Nursing Management, 27(5), 38,40,42.
Abstract: Integrating a traditional approach into a high-involvement culture can result in successful redesign. Examples of successful redesign efforts as well as those that failed are discussed

232.    O'Toole, R., & Moore, M. (1996). UTMB's clinical resource management initiative helps to analyze physician practice patterns. QRC Advisor, 12(7), 1-4-6; suppl 1 p.

233.    Niles, N., Tarbox, G., Schults, W., Swartz, W., Wolf, E., Robb, J., Plume, S., Nelson, E. C., & Nugent, W. (1996). Using qualitative and quantitative patient satisfaction data to improve the quality of cardiac care. Joint Commission Journal on Quality Improvement, 22(5), 323-35.
Abstract: BACKGROUND: In early 1993 leaders within the Hitchcock Clinic and cardiac services section at Dartmouth-Hitchcock Medical Center (Lebanon, NH) formed the Cardiac Services Improvement Group (CSIG) as a pilot program for patient-centered quality improvement (QI) at the sectional level. CSIG PROGRAM: For open heart surgery (OHS) and percutaneous transluminal coronary angioplasty (PTCA), a flowchart was constructed of sequential patient experiences. Content analysis of focus group discussions resulted in six key patient-defined quality characteristics: comfort, caring, certainty, convenience, communication, and cost. Linking of patient comments to points on the patient experience flowchart made it possible to determine where particular quality characteristics were most relevant. A patient satisfaction survey with questions that were specific to a patient experience and to a quality characteristic was mailed to 100 consecutively discharged OHS and PTCA patients; 35 of the 50 patients in each group responded. EVALUATING SUCCESS: Analysis of the survey results led to the formation of two QI teams. One team began work on development of a critical pathway for discharge preparation and identified marker questions to track and monitor pathway success in subsequent surveys. Another team began the development of protocols for more effective pain management during and after the PTCA procedure. A repeat patient satisfaction survey that took place from November 1994 to March 1995 suggested a global improvement in patient satisfaction for all patient experiences and all key quality characteristics. CONCLUSION: The CSIG pilot program of patients-based quality measurement and management at the sectional level has been successful in fostering QI team formation and has been associated with a positive deflection in patient-based quality measures. Additional sections of the medical center have initiated similar projects, beginning with process definition and focus groups

234.    Marrie, T. J., & Slayter, K. L. (1996). Nursing home-acquired pneumonia. Treatment options. [Review] [64 refs]. Drugs & Aging, 8(5), 338-48.
Abstract: Nursing home-acquired pneumonia (NHAP) is a diagnostic and therapeutic challenge, and antimicrobial therapy represents only 1 facet of the treatment of this disease. The nursing home population consists of a mixture of well, frail and dependent elderly. For some residents, supportive care may be the best therapeutic option. A variety of antimicrobial regimens have been proposed for the empirical therapy of NHAP; however, there are still very few data from controlled clinical trials that assess outcome. The clinical trials that have been completed support the concept that an early switch from intravenous to oral therapy can be successfully used to treat pneumonia affecting frail, often seriously ill, groups of patients. Annual influenza vaccine should be offered to all nursing home residents. This practice is about 50% effective in preventing hospitalisation and pneumonia, and about 80% effective in preventing death. The same level of evidence is not available to support the use of pneumococcal vaccine in this group; however, current practice suggests that all nursing home residents receive this vaccine on admission and once every 6 years thereafter. Frequently, knowledge about pneumonia is not applied as optimally as should be done. Care maps have been shown to reduce length of stay and shorten the time from emergency room entry until administration of antibiotic therapy by up to 3 hours. Areas for urgent research attention in patients with NHAP are: (a) proper studies to define the microbiological aetiology of NHAP (this requires bronchoscopy with sampling of the distal airways using a protected bronchial brush); (b) randomised controlled clinical trials of sufficient size to determine whether one antibiotic regimen is superior to another (currently most trials are designed to show that the agent under study is equivalent to a currently used agent); and (c) end-of-life decision making in the nursing home population. [References: 64]

235.    Latini, E. E. (1996). Trauma critical pathways: a care delivery system that works. Critical Care Nursing Quarterly, 19(1), 83-7.
Abstract: Continuous performance improvement in care a patient receives is of paramount importance to Robert Packer Hospital, a regional, accredited trauma center in rural Pennsylvania. In fall 1991, a care delivery system known as case management was introduced as a mode for achieving this continuous performance improvement goal. The staff members' experience with the initial development and use of a trauma critical pathway was first published in the November 1993 issue of Critical Care Nursing Quarterly. Now, 3 years later, case management has proven to be a viable means to accomplish the continuous performance improvement goal by enhancing the quality of care for trauma patients and their families throughout hospitalization. This article reviews the outcomes over the past 3 years as a result of case management and the use of trauma critical pathways

236.    Lasater, M. (1996). The effect of a nurse-managed CHF clinic on patient readmission and length of stay. Home Healthcare Nurse, 14(5), 351-6.
Abstract: Hospital readmission for exacerbation of symptoms of Congestive Heart Failure (CHF) is a major home healthcare problem and expense. To address this problem and curb the increasing expense and patient lifestyle disruption, a group of staff nurses at the Medical University of South Carolina Medical Center developed a nurse-managed clinic to follow all patients with CHF after discharge. Within 6 months of the clinic's operation, readmissions of these patients decreased by 4%, and the length of stay decreased by 1.6 days

237.    Kopetsky, E. (1996). CHIME. Chairman's message. Healthcare Informatics, 13(5), 92.

238.    Koch, M. O., & Smith, J. A. Jr. (1996). Influence of patient age and co-morbidity on outcome of a collaborative care pathway after radical prostatectomy and cystoprostatectomy. Journal of Urology, 155(5), 1681-4.
Abstract: PURPOSE: We determined whether standardized care patterns developed with a collaborative care methodology can be applied successfully across all patient groups with favorable effects on cost and quality. MATERIALS AND METHODS: We retrospectively analyzed financial and clinical outcomes in 109 radical retropubic prostatectomy and 47 radical cystectomy cases. Patients older than 70 years and/or with an American Society of Anethesiology status of 3 or greater were compared to younger, healthier patients undergoing these procedures. RESULTS: Standardized care patterns resulted in favorable financial and clinical outcomes in high and low risk patient groups. The only apparent difference was an increased need for rehospitalization after discharge for patients undergoing radical prostatectomy with a high American Society of Anesthesiology status. CONCLUSIONS: Standardized care patterns developed with a collaborative care methodology provide a high quality, cost-efficient approach to medical care. This methodology is applicable to all patient groups and is highly compatible with current medical practice

239.    Hogue, J. K., Kinahan, J. J., & Delcher, H. K. (1996). A hospital-based home health diabetes education model. Home Healthcare Nurse, 14(5), 372-7.
Abstract: For continuity in delivering healthcare across the continuum, an institutionally based home healthcare department was established at Georgia Baptist Medical Center, Atlanta, Georgia. The overall mission of home healthcare services is to maintain high levels of care while maintaining the lowest reasonable costs. Much of the department's patient care focuses on patients challenged with diabetes. This article describes the creation of a progressive, self-directed diabetes education model within this hospital-based home care program

240.    Hague, D. S. (1996). The Ohio Nurses Association presents "Clinical pathways: the careplans of the 90s" an independent study. Ohio Nurses Review, 71(5), 15-19.

241.    Hague, D. A. (1996). Clinical pathways: the careplans of the 90s: an independent study (continuing education credit). Ohio Nurses Review, 71(5), 15-8; quiz 19.

242.    Edelberg, C. (1996). 1996 CPT revisions will affect the ED; prepare now. Ed Management, 8(5), 54-6.

243.    Connors, K. (1996). Managed care and case management. Australian Nursing Journal, 3(10), 32-4.

244.    Borkowski, V. (1996). Asthma pathway slashes LOS in half, saves $2,300. Hospital Case Management, 4(5), 71-4.

245.    Bates-Jensen, B. M. (1996). Wound care nurses' judgements on healing time in chronic wounds. Ostomy Wound Management, 42(4), 36-8, 40,42 passim.
Abstract: With the current push to develop critical pathways for chronic wound patients, information on "normal" versus problematic wound healing is important. This descriptive study begins to define chronic wound healing time markers by examining clinicians' own healing expectations with pressure ulcers. A 30-item questionnaire concerning partial and full thickness pressure ulcers on the sacrum, trochanter and heel was sent to 272 wound/ET nurses. Total response rate was 32.3% with 74 analyzable questionnaires returned. Data was analyzed using descriptive statistics and correlations where appropriate. Results were: (1) The longer respondents thought it would take for wounds to heal, the more variable their responses. (2) Respondents viewed heel wounds as taking the longest to heal and were more certain about time to healing in sacral wounds. (3) Responses indicated longer healing times than those shown in recent studies looking at change in wound surface area. (4) Results on time of 3.2 weeks to autolytic debridement of wounds with black eschar does not differ greatly from published time for enzymatic debridement, in spite of guidelines stating that autolysis may take longer than other methods. This study demonstrates that there remains variability in wound nurses' perceptions of time to healing and, therefore, recent attempts at defining critical pathways may be premature

246.    Lumsdon, K. (1996). Clinical paths. Mapping care. Hospitals & Health Networks, 70(8), 86.

247.    Beckley, N. J. (1996). Managed care. Working with the finances... workers' compensation, case management, and rehabilitation. Rehab Management: The Interdisciplinary Journal of Rehabilitation, 9(3), 101-3.

248.    Beck, M. (1996). Holistic managed care: recognizing pathways towards integration. Imprint, 43(3), 49-50.

249.    Pon, D. (1996). Service plans and clinical interventions targeted by the oncology pharmacist. Pharmacy Practice Management Quarterly, 16(1), 18-30.
Abstract: Pharmacists are faced with a changing health care environment where they are being asked to demonstrate "value-added" to patient care. Because of the toxicity, complexity, intensity, and cost of cancer treatment, oncology pharmacists have opportunities to prevent adverse drug reactions, reduce costs, optimize drug regimens, and improve patient outcomes. Programs implemented by pharmacists practicing on a 40-bed adult inpatient oncology unit are described, including (1) chemotherapy quality improvement, (2) treatment of febrile neutropenia, and (3) management of peripheral blood cell transplant patients.  (Abstract by: Author)

250.    Musfeldt, C. D. (1996). Outpatient critical pathways: five advantages for physicians who act now. Physician Executive, 22(4), 10-1.

251.    McKinlay, L. (1996). Preadmission testing, assessment reduce cesarean LOS. Hospital Case Management, 4(4), 55-8.

252.    Kegel, L. M. (1996). Case management, critical pathways, and myocardial infarction. [Review] [46 refs]. Critical Care Nurse, 16(2), 97-104, 106-108, 110-112.
Abstract: Case management is an innovative way to simultaneously modify healthcare delivery, uphold standards of care, and reduce healthcare costs. The case manager oversees the patient's condition, progress, and consumption of resources. Information is constantly analyzed and used to regulate treatment plans in accordance with the critical pathways. The goal of this regulation is to produce outcomes that serve the patient and the healthcare system. The complexity of individualized patient care can require an unlimited number of pathways if all variances are considered. If all variances are not considered, then the quality of care is hindered, rehospitalization occurs, and the goals of the critical pathways are not achieved. Therefore, effective use of case management and critical pathways involves flexible guidelines, maintains focus on outcomes, enhances efficiency, increases cost-effectiveness, and retains a high quality of patient care. [References: 46]

253.    Janssen, M. K. (1996). Initiating MAPs in a rural hospital. Surgical Services Management, 2(4), 40-1, 43.

254.    Gordon, D. B. (1996). Critical pathways: a road to institutionalizing pain management. Journal of Pain & Symptom Management, 11(4), 252-9.
Abstract: Effective strategies to increase the visibility of pain and the accountability of health-care professionals for the treatment of pain are needed to improve the quality of pain management. Critical pathways are tools used to plan and document care for patients within a system of case management. Case management models of care focus on decreased cost, better coordination of services, and improved patient outcomes. This article describes how critical pathways are being used in one setting within a system of case management to help increase awareness of pain as a problem and to institutionalize pain management. As institutions seek to implement outcome-based practice systems, many are turning to the critical pathway to influence practice patterns. Critical pathways provide the vehicle to articulate and implement a standard for quality pain management and a mechanism to analyze persistent failures in achieving desired outcomes of care. Using pathways to track and monitor care promises to uncover clinical barriers to pain management and provide an impetus to increase clinician accountability for pain relief

255.    Fuzy, J. L. (1996). Specialty training in a managed care system. Home Health Care Management & Practice, 8(3), 29-35.

256.    Elliott, J. (1996). Case management: a key to quality. Healthcare Informatics, 13(4), 75-77, 79-81.

257.    East, T. D., & Morris, A. H. (1996). Decision support systems for management of mechanical ventilation. Respiratory Care, 41(4), 327-40.

258.    Sanchez, Y., Lovell, M., Marin, M. C., Wong, P. E., Wolf-Ledbetter, M. E., McDonnell, T. J., & Killary, A. M. (1996). Tumor suppression and apoptosis of human prostate carcinoma mediated by a genetic locus within human chromosome 10pter-q11. Proceedings of the National Academy of Sciences of the United States of America, 93(6), 2551-6.
Abstract: Prostate cancer is the second leading cause of male cancer deaths in the United States. Yet, despite a large international effort, little is known about the molecular mechanisms that underlie this devastating disease. Prostate secretory epithelial cells and androgen-dependent prostate carcinomas undergo apoptosis in response to androgen deprivation and, furthermore, most prostate carcinomas become androgen independent and refractory to further therapeutic manipulations during disease progression. Definition of the genetic events that trigger apoptosis in the prostate could provide important insights into critical pathways in normal development as well as elucidate the perturbations of those key pathways in neoplastic transformation. We report the functional definition of a novel genetic locus within human chromosome 10pter-q11 that mediates both in vivo tumor suppression and in vitro apoptosis of prostatic adenocarcinoma cells. A defined fragment of human chromosome 10 was transferred via microcell fusion into a prostate adenocarcinoma cell line. Microcell hybrids containing only the region 10pter-q11 were suppressed for tumorigenicity following injection of microcell hybrids into nude mice. Furthermore, the complemented hybrids undergo programmed cell death in vitro via a mechanism that does not require nuclear localization of p53. These data functionally define a novel genetic locus, designated PAC1, for prostate adenocarcinoma 1, involved in tumor suppression of human prostate carcinoma and furthermore strongly suggest that the cell death pathway can be functionally restored in prostatic adenocarcinoma

259.    Morrissey, J. (1996). Software helps find critical pathways [news]. Modern Healthcare, 26(11), 10.

260.    Vrooman, W. P. (1996). Care mapping: measuring clinical and financial outcomes. Healthcare Information Management, 10(1), 31-6.
Abstract: A medical center's nursing units were asked to develop care maps for s elected DRGs, with the goal of improving the level of patient care, reducing cost, and curtailing length of stay. However, none of the efforts provided a tangible way to measure the results. After a comprehensive study effort, the medical team decided that the missing element was better management of the emotional aspects of care.  (Abstract by: Author)

261.    Shulkin, D. J., & Ferniany, I. W. (1996). The effect of developing patient compendiums for critical pathways on patient satisfaction. American Journal of Medical Quality, 11(1), 43-5.
Abstract: We examined the impact of developing a patient compendium to a critical pathway on patient satisfaction scores. It was our hypothesis that by sharing the contents of a critical pathway, by using a patient compendium, we would improve patient satisfaction by establishing realistic patient expectations for patients undergoing cardiac bypass graft surgery. A satisfaction survey was sent to patients before the hospital began to use the patient compendium to the pathway and to another group of patients after initiation of a compendium. Although there were some trends suggesting an improvement in patient satisfaction scores, there was no statistical difference in satisfaction before or after the compendium was in use

262.    Matthews, P., Carter, N., & Smith, K. (1996). Using data to measure outcomes. Healthcare Information Management, 10(1), 3-16.
Abstract: The health care marketplace is beginning to demand that providers develop and provide outcomes data. But implementing a process of collecting outcomes data can be very labor intensive. Planning must include defining outcomes, understanding how outcomes are used in analysis and decision-making activities, identifying data sources, and identifying the users.  (Abstract by: Author)

263.    Gideon, D. M., Morehead, K. E., & Petno, D. C. (1996). Uniform billing data in hospital planning, marketing and clinical guidelines. American Journal of Medical Quality, 11(1), S63-5.
Abstract: Hospitals are major users of inpatient discharge data from the Pennsylvania Health Care Cost Containment Council (PHC4). A hospital planning and marketing executive and a hospital network consultant describe different uses for the data; including planning, competitor analysis, and development of clinical pathways. The PHC4 data are useful because they are reported in a uniform format for all facilities and they provide detailed clinical and financial information. In addition, Pennsylvania's data include an admission severity measure to permit risk adjustment. These data have enabled these institutions to enhance their clinical and financial performance

264.    Fridlin, C. (1996). Using severity-adjusted data to impact clinical pathways. Healthcare Information Management, 10(1), 23-30.
Abstract: Feeling the weight of managed care, doctors and nurses at a Midwestern health system have joined forces to reduce costs and average lengths of stay (LOS) in a key practice area--orthopedics. The result has been a 40 percent decrease in average length of stay over a three-year period.  (Abstract by: Author)

265.    Yaksic, J. R., DeWoody, S., & Campbell, S. (1996). Case management of chronic ventilator patients. Reduce average length of stay and cost by half. Nursing Case Management, 1(1), 2-10.
Abstract: The implementation of the case management model and the use of critical pathways has become a major strategy to improve quality of care and cope with measuring and managing costs. Grant Medical Center, a 640-bed Level I Trauma Center, began case managing its chronic ventilator patients in July, 1993. A 30-day critical pathway was developed using a multidisciplinary team approach. In case managing these patients, many problematic issues were identified, such as lack of adequate involvement by staff experienced in specific disciplines and multiple physician decision makers for each case. By increasing multidisciplinary collaboration, care of these patients was systematically changed and streamlined. Over a 2-year period, the average length of stay for chronic ventilator patients decreased from 74.5 days to 41.9 days, and the average cost per case decreased from $189,080 to $107,019

266.    Wooster, L. D., & Forthman, M. T. (1996). Establishing a proper perspective on clinical pathways before implementing a clinical improvement program. Best Practices & Benchmarking in Healthcare, 1(2), 84-8.
Abstract: The presumed stellar characteristics of clinical pathways have grown in unearthly proportions to the extent that our expectations of pathway utilization are unrealistic and unfounded. Therefore, before expectations go unmet and dissatisfaction with clinical pathway outcomes becomes prevalent, we must objectively analyze the clinical pathway phenomenon and understand the origins, elements, and purpose of this clinical improvement technique

267.    Walrath, J. M., Owens, S., & Dziwulski, E. (1996). Success stories. Case management -- a vital link to performance improvement. Nursing Economics, 14(2), 117-122.
Abstract: A pilot program in the cardiac surgical service resulted in a $1.3 million reduction in patient charges while quality patient outcomes were sustained. Pivotal to the success of the program was the implementation of the case manager role

268.    Strassner, L. F. (1996). The ABCs of case management. A review of the basics. [Review] [27 refs]. Nursing Case Management, 1(1), 22-30.
Abstract: As managed care continues to emerge as a dominant structure for delivering and reimbursing health care, nursing is responding and assisting in reshaping the health care system. Nursing case management as a new delivery of care includes providing and coordinating care across the continuum. The continuum includes prevention, wellness, acute, rehabilitation, long term, and hospice care. Various definitions of case management exist and are dependent on the discipline that employs them, the setting in which they are implemented, and the personnel and staff mix used in their implementation. Patient identification, assessment, planning, implementing and coordinating and evaluating the delivery of service and patient outcomes are components common to all case management models. The nurse case manager should be minimally educationally prepared at the baccalaureate level. She/he should also have expert clinical skills, knowledge of the health care system, health care finances, and legal issues and be an effective communicator. Within the case management model the case manager will use various tools to achieve clinical, quality, and economic outcomes. Some of these tools include practice guidelines, critical paths, variance analysis, protocols/algorithms, risk assessment, and outcome measurement tools. [References: 27]

269.    Spatz, M. W., Morales, L. O., & Bohannan, D. A. (1996). Integrated monitoring and evaluation in the ambulatory care setting. Journal for Healthcare Quality, 18(2), 31-6; quiz 37.
Abstract: The ambulatory care area has been slower to develop integrated monitor ing tools than have hospital-based systems. This article outlines some reasons for this slowness, elaborates on the need for further developments in this field, and describes one multispeciality clinic's process to meet this goal.  (Abstract by: Author)

270.    Omdahl, D. J. (1996). Managing outcomes & utilization in the home. Infocare,  34,36.

271.    McPhee, M., & Hoffenberg, E. (1996). Nursing case management for children with failure to thrive. Journal of Pediatric Health Care, 10(2), 63-73.
Abstract: The case management approach is described for children with nonorganic failure to thrive in the pediatric tertiary care setting. An advanced practice nurse facilitated the organization of a planning committee, the construction of a care path, and the evaluation of the case management model. A 4-day care path is presented to show staff nursing functions in the nurse case manager role. Special issues are discussed for developing care paths for organic-based failure to thrive where parent reports can help guide health care interventions.  (41 ref)

272.    Mateo, M. A., & Newton, C. (1996). Managing variances in case management. [Review] [15 refs]. Nursing Case Management, 1(1), 45-51.
Abstract: Timely management of variances is vital for cost effective patient care. A multifaceted approach that involves the healthcare team, patient, and family facilitates the identification and management of variances as they occur. The critical path can be used to monitor variances that influence fiscal outcomes in select patient populations. Strategies are described that can be used to monitor and manage variances, including developing a mechanism for monitoring and managing variances, implementing that mechanism, and evaluating the process for usability. Monitoring variances includes choosing tools that will be used and staff who will assume primary responsibility, and initiating an outcome analysis program. Managing variances comprises organizing an interdisciplinary committee, establishing a communication plan, creating strategies, and using continuous quality improvement teams. [References: 15]

273.    Maehling, J. A., & Badger, K. (1996). Information systems tools available to the case manager. Nursing Case Management, 1(1), 35-40.
Abstract: Regardless of the setting, the role of the nurse as a manager of care continues to grow and develop. The nurse case manager needs to have vital information readily available to facilitate critical thinking, analysis, and decision-making on the appropriateness of care provided to patients and to ensure that optimal outcomes are achieved. While there are a variety of clinical information systems available, it is evident that the complexity of the case manager's information needs presents challenges for software developers. Accordingly, nurse case managers must take an active role in defining and communicating their needs. The purpose of this article (the first of two) is to present a general overview of the information needs of the nurse case manager and the computerized information system tools available (and emerging) to meet these needs. A follow-up article in the next issue of Nursing Case Management will focus on a typical clinical information system selection process; outline specific ways the nurse case manager can effectively influence that process; and provide a checklist that will enable the nurse case manager to assist the institution in selecting and implementing the most appropriate system.  (2 ref)

274.    MacPhee, M., & Hoffenberg, E. (1996). Nursing case management for children with failure to thrive. Journal of Pediatric Health Care, 10(2), 63-73.
Abstract: The case management approach is described for children with nonorganic failure to thrive in the pediatric tertiary care setting. An advanced practice nurse facilitated the organization of a planning committee, the construction of a care path, and the evaluation of the case management model. A 4-day care path is presented to show staff nursing functions in the nurse case manager role. Special issues are discussed for developing care paths for organic-based failure to thrive where parent reports can help guide health care interventions

275.    Leininger, S. M. (1996). Tools for building a successful orthopaedic pathway. Orthopaedic Nursing, 15(2), 11-9.
Abstract: In this arena of ever-changing health care, critical pathways have been identified as a tool to analyze cost as well as improve patient care and resource utilization. The Orthopaedic Department of Allegheny General Hospital was one of the first departments to begin the process of developing critical pathways with DRG :209, Total Joint Replacements. This article explains how the multidisciplinary team members used the Continuous Quality Improvement process through the use of various questionnaires, tools, and tracking documents in identifying ways to improve customer services

276.    Kennelly, R. J. (1996). IEEE standards for physical and data communications... Institute of Electricians and Electronic Engineers. Biomedical Instrumentation & Technology, 30(2), 172-175.

277.    Haines, P. (1996). ARP under construction for the postanesthesia care unit... Anticipatory Recovery Plan. Breathline, 16(2), 6-8.

278.    Guthrie, S. (1996). Laminectomy: an outpatient approach. Nursing Case Management, 1(1), 31-4.

279.    DeWeese, J. (1996). Best practices for smoking cessation intervention for hospitalized patients. Indiana Medicine, 89(2), 181-3.
Abstract: A multi-disciplinary workgroup of health care professionals and consumers has developed evidence-based best practices guidelines, an algorithm and clinical pathways for smoking cessation intervention for hospitalized patients. These practice recommendations can be adapted for implementation in managed care settings

280.    Brawer, M., Parson, R., Costa, M., & Scheil, B. (1996). An actuarial model approach to assessing the impact of serial testing for prostate cancer using the Tandem PSA assay. Clinical Laboratory Management Review, 10(2), 157-9.
Abstract: This article summarizes an analytical approach to modeling prostate cancer detection scenarios that health-care plans, i.e., managed care organizations, can use to assist them in making early detection policy decisions. The actuarial modeling approach incorporates current variations in clinical practice with costs for the purpose of generating per member per month outputs. The intent of this approach is to provide laboratories with a tool to provide a value-added service to their managed care customers. The model can be tailored to an array of managed care plans and payer financial arrangements. Included here is a summary of an oral presentation from the Outcomes Conference at the CLMA meeting in Minneapolis, Minnesota in August of 1995. This material was presented by Robert Parson.  (Abstract by: Author)

281.    Aspling, D. L., & Lagoe, R. (1996). Benchmarking for clinical pathways in hospitals: a summary of sources. [Review] [23 refs]. Nursing Economics, 14(2), 92-7.
Abstract: Benchmarks are criteria and standards for resource expenditure, as well as other variables, derived from organizations or communities which have been identified as models of the most effective and efficient practices. The development of benchmarks is crucial to reducing lengths of stay and related costs in hospitals. Useful sources for benchmarking data and how to access them are summarized. [References: 23]

282.    Walls, R. M., Cannon, C. P., & Teich, J. (1996). Thrombolysis "door-to-drug" interval [letter; comment]. Academic Emergency Medicine, 3(3), 285; discussion 286-7.
Notes: Comments: Comment on: Acad Emerg Med 1995 Jul;2(7):603-9

283.    Valentine, C. J., & Phillips, S. M. (1996). Incorporating critical pathways into the management of pediatric nutrition support. Topics in Clinical Nutrition, 11(2), 48-52.
Abstract: Pediatric nutrition support (PNS) presents a unique challenge to the clinician. Nutrients need to be given to the pediatric patient to overcome catabolic events and sepsis while maintaining both tissue integrity and growth. Strategies for nutrition support have become, therefore, increasingly diagnosis specific. To further utilize individualized guidelines, critical pathways (CP) can be developed to ensure the timely incorporation of nutrition support. Critical pathways are protocols that function to guide the delivery of health care, and the CP diagrams offer a visible reminder of the support necessary for patient care. This article describes the development of a CP and the integration of nutrition support into the CP for an infant on extracorporeal membrane oxygenation (ECMO).  (18 ref)

284.    Spath, P. L. (1996). Solving the perioperative path dilemma. Hospital Case Management, 4(3), 44-6.

285.    Skarzynski, J. (1996). The continuum of care protocol: a strategic response to Joint Commission change. Health Care Supervisor, 14(3), 64-77.
Abstract: Changing mandates of the Joint Commission on Accreditation of Healthcare Organizations, including the 11 functional standards, the nine dimensions of performance, and the interdisciplinary approach, are reviewed. One hospital, City Hospital, strategically managed this change by marrying the principles of strategic management and continuous quality improvement. The end result of this pursuit was the production of a technology--a continuum grid--that helps to address accountability for hospitalwide functions, dimensions of performance, and interdisciplinary approaches while also addressing the need for a clinical pathway of care. The use of the continuum of care grid and steps to achieve a similar technology are identified.  (Abstract by: Author)

286.    Schoenenberger, R. A., Pearson, S. D., Goldhaber, S. Z., & Lee, T. H. (1996). Variation in the management of deep vein thrombosis: implications for the potential impact of a critical pathway. American Journal of Medicine, 100(3), 278-82.
Abstract: PURPOSE: To evaluate the potential impact of a practice guideline in the form of a critical pathway on variation and quality of care in patients with deep vein thrombosis (DVT). METHODS: Goals were identified for key steps and processes that were believed to be important for meeting a length-of-stay (LOS) goal of 5.5 days, and for improving quality of care for patients with DVT. Data collected via chart review were used to determine the percentage o patients with uncomplicated DVT admitted in the year after October 1, 1992, whose management would have met these goals. RESULTS: Only 11 (12%) of 92 eligible patients with a primary discharge diagnosis of DVT met the LOS goal. In 30%, the activated partial thromboplastin time (aPTT) was >60 seconds within a target of 12 hours after admission. The goals for the initiation of warfarin (within 12 hours after aPTT >60 seconds) and the achievement of a therapeutic international normalized ratio (INR) level (within 120 hours) were met in 51% and 58% of patients, respectively. The target duration of intravenous heparin therapy was achieved in 78% of patients. Only 18% of patients, however, were discharged within 12 hours after 96 hours of heparin therapy had been given and a therapeutic INR had been achieved. CONCLUSIONS: These data demonstrate considerable variation in management of uncomplicated DVT at a single hospital, suggesting that a critical pathway could have impact on both LOS and quality of care

287.    Riddle, M. M., Dunstan, J. L., & Castanis, J. L. (1996). A rapid recovery program for cardiac surgery patients. American Journal of Critical Care, 5(2), 152-9.
Abstract: Despite a strong national commitment to excellence in healthcare, the available resources are limited. Cardiac surgery consumes more healthcare resources than any other single treatment. It is imperative that healthcare professionals evaluate the traditional methods used to deliver quality care. Rapid recovery programs have been implemented in response to this challenge. The purpose of this article is to discuss development, implementation, and outcome evaluation of a rapid recovery program for cardiac surgery patients in a single health center. A multidisciplinary team examined care before, during, and after surgery, as well as after discharge. The team also evaluated standards of care and CARE Pathways. Changes in protocols were made to prevent the predictable complications of cardiac surgery. A decrease in intubation time, respiratory infections, wound infections, laboratory procedures, length of stay, and costs has been demonstrated. In a follow-up patient and family survey, high satisfaction with nursing care, patient and family education, and length of hospitalization has been voiced. Anticipated goals have been exceeded and improvements in standards continue to be made

288.    Petty, G. M. (1996). Computerized care tracks: a work redesign tool for the multiskilled health care practitioner. Topics in Emergency Medicine, 18(1), 35-9.
Abstract: The health care industry, along with other types of industries, is redesigning the way work is being accomplished. Emergency departments are moving from using specialized workers to using multiskilled health care practitioners. Computerized care tracks are a work redesign tool that will help the multiskilled worker accomplish his or her job responsibilities. The article defines work redesign, multiskilled health practitioner, and computerized care tracks. In addition, steps to consider when a computerized care track is being configured are outlined, and methods to operationalize the track in an emergency department are discussed.  (5 ref)

289.    Pearson, S. D., Lee, T. H., McCabe-Hassan, S., Dorsey, J. L., & Goldhaber, S. Z. (1996). A critical pathway to treat proximal lower-extremity deep vein thrombosis. American Journal of Medicine, 100(3), 283-9.
Abstract: To address variation in treatment of deep vein thrombosis (DVT) while maximizing the efficiency and quality of care, our institution developed a critical pathway guideline. This paper presents this critical pathway and the clinical rationale underlying its recommendations. The DVT pathway synthesizes recommendations for all aspects of patient care, including laboratory evaluation at admission, dosing and management of heparin therapy, timing of warfarin initiation, elements of patient education, discharge planning, and anticipated duration of heparinization and hospitalization. Differences among interpretations of the medical literature, patient populations, physician skills, test availability, and other variables make it unlikely that all elements of this pathway would best meet the needs of another institution. Nevertheless, the critical pathway format and the specific contents of this pathway may serve as a useful benchmark for others involved in creating clinical guidelines for this patient population

290.    Paz, H. L., & Livingston, J. (1996). Using a benchmarking system to improve patient care and assist in technology assessment. Physician Executive, 22(3), 10-2.
Abstract: Clinical benchmarking is a tool of CQI that can be used to improve outcomes in areas of strategic importance. While it is a simple tool, benchmarking requires a long-term commitment from the entire organization involved in its use to be successful. Benchmarking is a means of setting goals or targets. As a tool used for continuous quality management, benchmarking is an ongoing activity of comparing an organization's service, product, or process with similar ones outside the organization that are known to be the best. In attempting to emulate or surpass "best practice," an organization must set challenging but attainable goals and reach them with a plan of realistic and efficient actions.  (Abstract by: Author)

291.    Noedel, N. R., Osterloh, J. F., Brannan, J. A., Haselhorst, M. M., Ramage, L. J., & Lambrechts, D. (1996). Critical pathways as an effective tool to reduce cardiac transplantation hospitalization and charges. Journal of Transplant Coordination, 6(1), 14-9.
Abstract: A critical pathway is a component of managed care focusing on outcome-oriented, cost-effective care. This retrospective review of 74 cardiac transplants in 72 patients evaluated the influence of critical pathways on clinical management, length of hospitalization, and hospital charges. Transplant patients were divided into group 1 (n = 51), which received standard primary nursing care, and group 2 (n = 23), which received nursing case management using a critical pathway. The number of intensive care unit days for group 2 was significantly smaller than for group 1, as were duration of hospitalization and hospital charges. The critical pathway provided for systematic delivery of care and decreased length of hospitalization and charges without compromising safety or quality

292.    Musser, D. J., Calligaro, K. D., Dougherty, M. J., Raviola, C. A., & DeLaurentis, D. A. (1996). Safety and cost-efficiency of 24-hour hospitalization for carotid endarterectomy. Annals of Vascular Surgery, 10(2), 143-6.
Abstract: The safety and cost savings of carotid endarterectomy (CEA) were determined with guidelines developed after vascular "critical pathways" were implemented. Using these guidelines, our goal was to admit patients the day of surgery and to discharge them the next morning. Morbidity, mortality, readmission rates, same-day admissions, duration of stay, and hospital costs were compared between patients undergoing CEA who were electively admitted between September 1, 1992 and August 31, 1993 (group 1) and January 1, 1994 and March 31, 1995 (group 2). Between these two time periods, vascular critical pathways were instituted and all preoperative examinations were performed on an outpatient basis. The majority of CEAs were performed with the patient under general anesthesia. We found no significant differences between group 2 (n = 68) vs. group 1 (n = 40) in terms of mortality (1.5% [1 of 68] vs. 2.5% [1 of 40]), cardiac events (2.9% [2 of 68] vs. 2.5% [1 of 40]), neurologic events (2.9% [2 of 68] vs. 2.5% [1 of 40]), or readmission rate (1.5% [1 of 68] vs. 0% [0 of 40]). Same-day admissions were significantly higher (94% [64 of 68] vs. 5% [2 of 40]; p < 0.0001), and average duration of stay was significantly lower (1.3 vs. 5.1 days; p < 0.0001) in group 2 vs. group 1, respectively. Hospital charges were decreased by $5510 per patient in group 2. We conclude that hospital costs can be significantly reduced for most patients undergoing CEA when they are admitted on the day of surgery and discharged the following morning, with no negative impact on morbidity and mortality

293.   Mulrow, C. D. (1996). Reconnoitering critical pathways and guidelines [editorial; comment]. Journal of General Internal Medicine, 11(3), 185-6.
Notes: Comments: Comment on: J Gen Intern Med 1996 Mar;11(3):139-46, Comment on: J Gen Intern Med 1996 Mar;11(3):174-5, Comment on: J Gen Intern Med 1996 Mar;11(3):176-8

294.    Lee, T. H. (1996). Beyond Guidelines. Can general internists show the (critical) paths? [see comments]. Journal of General Internal Medicine, 11(3), 174-5.
Notes: Comment in: J Gen Intern Med 1996 Mar;11(3):185-6

295.    King, B. (1996). Hospital redesign complements new PTCA pathway. Hospital Case Management, 4(3), 39-42.

296.    Kimberlin, L., & Bregman, J. (1996). Postconceptional age as the basis for neonatal case management. Neonatal Network, 15(2), 5-13.
Abstract: Managing the care of the very preterm infant can become a maze of diagnoses, treatments, and tests that blur progress and expectations along an infant's extended course in the NICU. Yet the health care environment demands that comprehensive, high-quality, cost-effective care be provided each infant and family entrusted to our care. Critical pathways based on gestational age at birth and postconceptional age throughout the hospital stay facilitate the necessary goal-oriented, interdisciplinary approach to infant care by providing consistency, flexibility, and quality management

297.    Gibb, H., & Banfield, M. (1996). The issue of critical paths in Australia: where are they taking us?. [Review] [45 refs]. Nursing Inquiry, 3(1), 36-44.
Abstract: This discussion paper sets out some major concerns with the introduction of critical paths into the Australian health care system. It is argued that in their current form as devised in North America, critical paths may not be appropriate to our organisation of health care and may in fact be detrimental to the development of nursing practice. The discussion centres around the socio-political context of the development of managed care in North America, as well as research findings from the implementation of critical paths in an Australian hospital. [References: 45]

298.    Esquenazi, A., & Meier, R. H. 3rd. (1996). Rehabilitation in limb deficiency. 4. Limb amputation. [Review] [42 refs]. Archives of Physical Medicine & Rehabilitation, 77(3 Suppl), S18-28.
Abstract: This self-directed learning module highlights new advances in this topic area. It is part of the chapter on rehabilitation in limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article reviews the phases of amputation rehabilitation from preoperative stages to community reintegration and long-term follow-up. The various indications for artificial limb components for the upper and lower limb amputee and the expected functional levels based on level of amputation are discussed. New concepts of critical pathways are also introduced as guidelines in optimizing the rehabilitation of the amputee. The reader is directed to other relevant literature as well, in an attempt to enhance knowledge in this area of rehabilitation. [References: 42]

299.    Esposito, M. P., & Hughes, J. M. (1996). Restructuring. Positioning RC services for success: a year of change and making change work. AARC Times, 20(3), 42-5.

300.    Dubbs, W. H., & Weber, K. (1996). AARC survey measures effects of restructuring on respiratory care nationwide. AARC Times, 20(3), 29-32, 35-40.

301.    Davis, J. T., Allen, H. D., Powers, J. D., & Cohen, D. M. (1996). Population requirements for capitation planning in pediatric cardiac surgery. Archives of Pediatrics & Adolescent Medicine, 150(3), 257-9.
Abstract: OBJECTIVE: To determine the population number necessary to generate a sufficient volume of pediatric cardiac surgeries to allow accurate prediction of resource utilization. DESIGN: All pediatric cardiac surgical patients receive care in our institution by means of only four clinical pathways that are based on acuity, not diagnosis or procedure. This allows accurate tracking of resource utilization. Based on available information, 750 consecutive surgically treated patients were retrospectively assigned to a pathway. They were subsequently subdivided into study groups of decreasing sizes from 150 to 35. Variability of pathway distribution from group to group was examined as a measure of the ability to predict resource utilization based on group size. Pediatric cardiac statistics from the state of Ohio were then used to extrapolate to the population base necessary to generate each group size. SETTING: A regional pediatric cardiac referral center. PATIENTS: All sequential patients who underwent pediatric cardiac surgery between July 1991 and January 1994. RESULTS: Statewide statistics showed that a population base of 1 million people generates 100 pediatric cardiac operations. Groups of 100 patients or greater had minimal variation in pathway distribution from group to group, allowing accurate prediction of hospital charges. This was not true for groups of 50 patients or less. CONCLUSIONS: Resource utilization for pediatric cardiac surgery can be accurately predicted in a capitated setting for populations of 1 million covered lives (100 procedures) or greater. For populations of 500 000 covered lives or less, variability of case mix is great enough to suggest the need for a more individualized payment mechanism

302.    Cronin, Y. M., & Bahrke, L. S. (1996). An epidural clinical pathway: a new generation for clinical pathways. Aspmn Pathways, 5(1), 1, 3-4.

303.    Blaylock, B., & Murray, M. (1996). Case management: a new practice model for ET nurses. Journal of Wound, Ostomy, & Continence Nursing, 23(2), 66-72.
Abstract: An examination of wound, ostomy, and continence nursing practice provides ideas for improving patient care and for role development of the ET nurse. During this period of rapid health care reform, opportunities to expand ET nursing practice must be explored. For many ET nurses, care of the patient with an ostomy remains a primary focus. The fitting of prosthetic equipment and patient education concerning ostomy care may not, however, be enough to demonstrate the impact of ET nursing care on the outcome of patients with an ostomy. Caring for the patient undergoing gastrointestinal surgery by means of a case management model is a new option for ET nurses. Nurse case managers focus on the patient and the impact of illness from admission until discharge. They are accountable for coordinating the multidisciplinary team who cares for the patient and for the evaluation of outcomes. ET nurses must evaluate the outcomes of their care to demonstrate the continued need for our specialty practice. This article describes the efforts of ET nurses at a tertiary care center in the Midwest to develop a case management system for patients undergoing gastrointestinal surgery within their practice. The process of developing a critical pathway, or care map, is also described

304.    Greene, J. (1996). Retooling without layoffs. Modern Healthcare, 26(9), 76-8, 80, 82.
Abstract: Hospitals nationwide are looking for ways to cut expenses in hopes of attracting managed-care contracts and in preparation for expected restrictions in the growth of the Medicare and Medicaid programs. But they're learning that the pink slip usually isn't the best way to achieve those cost reductions.  (Abstract by: Author)

305.    Lands, R. H. (1996). A piece of my mind. Epiphany. JAMA, 275(7), 564.

306.    Shane, R. R. (1996). Pharmacy without walls. American Journal of Health-System Pharmacy, 53(4), 418-25.
Abstract: Attributes of excellence in pharmacy management are described: big-picture thinking, the ability to exploit change, and willingness to take risks. Big-picture thinking means understanding trends that are shaping health care in order to determine where pharmacy fits. Health systems look beyond inpatient care and use case managers to maximize resource use; pharmacists might serve as case managers. Managed care has caused physicians to be more receptive to resource-management strategies, such as clinical pathways; pharmacists can collaborate in the development of clinical pathways. Pharmacists can serve as physician extenders; for example, by conducting anticoagulation or hypertension clinics. Pharmacists need flexibility to adapt to changes in the internal organization of acute care institutions; they will need to learn about the clinical, behavioral, operational, and fiscal aspects of managing the total patient. New reporting relationships give pharmacists the opportunity to demonstrate to other members of the health care team their role in preventing, managing, and resolving drug-related problems throughout the continuum of care. Risk-taking can mean setting ambitious goals. By setting and achieving ambitious goals for products and services, pharmacists can raise patients' and other health care providers' expectations for pharmacy services. Pharmacists' success will depend on their willingness to experiment with new services and discard services that do not substantially advance patient care. Pharmacists must monitor changes in the provision of health care, determine the implications for their practice and seek opportunities for participation outside the walls within which they have traditionally practiced

307.    Jaggers, L. D. (1996). Differentiation of critical pathways from other health care management tools. American Journal of Health-System Pharmacy, 53(3), 311-3.

308.    Wojner, A. W. (1996). Outcomes management: an interdisciplinary search for best practice. [Review] [18 refs]. AACN Clinical Issues, 7(1), 133-45.
Abstract: Rising U.S. health-care costs have resulted in mandates to reform the health system. Payors are closely scrutinizing care delivery and have empowered themselves as gatekeepers for consumer health-care access. In the late 1980s, outcomes management emerged as an interdisciplinary process advocating the measurement of health outcomes among populations undergoing medical care. Outcomes management provides a mechanism to foster development of patient-driven health services aimed to impact clinical quality through intermediate and long-term outcome analysis. Outcomes measurement facilitates ongoing enhancement of interdisciplinary health-care delivery, enabling determination of "best" practice and identification of opportunities for practice improvement. The advanced practice nurse's unique educational preparation provides a framework for development of the prerequisite leadership qualities necessary to cultivate an outcomes management program. [References: 18]

309.    Shea, C. A. (1996). Entrepreneur for out times: an interview with Karen Zander. Journal of the American Psychiatric Nurses Association, 2(1), 23-30.

310.    Scott, K. (1996). Case management: a quality process. Topics in Health Information Management, 16(3), 58-64.

311.    Roy, P., & Janson, E. (1996). CHF (congestive heart failure) path begins in ED, saves hospital $1,000 per patient. Hospital Case Management, 4(2), 23-6.

312.    Robertson, C. (1996). Critical paths: a tool to improve skiing on the slopes of managed care. Tennessee Nurse, 59(1), 19-22.

313.    Rawsky, E. (1996). Building a case management model in a small community hospital [see comments]. Nursing Management, 27(2), 49-51.
Notes: Comment in: Nurs Manage 1997 Aug;28(8):12, 14
Abstract: Facilities moving toward case management can help promote success by borrowing from the experience of others and then making necessary modifications to incorporate the unique needs and characteristics of each institution. The author has used this approach in developing a program well suited for application to a small community hospital

314.    Odderson, I. R. (1996). Pathways to quality care at lower cost. Physical Medicine & Rehabilitation Clinics of North America, 7(1), 147-65.

315.    McEachern, S. (1996). Orthopedics one of easiest product lines to integrate. Health Care Strategic Management, 14(2), 1-20-3.

316.    Maturen, V., & Van Dyck, L. (1996). Using outcome-based critical pathways to improve documentation. Home Health Care Management & Practice, 8(2), 48-58.

317.    Lykins, T. C. (1996). Nutrition support clinical pathways. Nutrition in Clinical Practice, 11(1), 16-20.
Abstract: With growing concerns over cost containment, hospitals are using clinical pathways to standardize health care and reduce costs. Clinical pathways designate the actions and services that patients should receive at specified time intervals throughout the hospital stay. Although most clinical pathways have been created for specific diseases or diagnoses, the nutrition support team at Tallahassee Memorial Regional Medical Center has developed clinical pathways for enteral and parenteral therapies. These pathways allow the team to track patient outcomes related to nutrition and to document variances when provisions fall outside the pathways. Variances are tallied on a quarterly basis and reported to the hospital Nutrition Support Committee. As data collection continues, trends emerge that guide the team to take appropriate corrective actions. Patient care is continuosly improved by incorporating these corrective actions into the pathways

318.    Kitchiner, D., Davidson, C., & Bundred, P. (1996). Integrated care pathways: effective tools for continuous evaluation of clinical practice. [Review] [26 refs]. Journal of Evaluation in Clinical Practice, 2(1), 65-9.
Abstract: The critical examination of clinical practice should be an integral part of patient care. It includes the development and implementation of guidelines, together with continuous evaluation of clinical process and outcomes to improve the quality of care provided. Clinical audit has not been successful in achieving this. The use of Integrated Care Pathways facilitates the introduction of guidelines and the continuous evaluation of clinical practice. Improvements are achieved by frequently revising the pathways to reflect current, local best practice. Integrated Care Pathways define the expected course of events in the care of a patient with a particular condition, within a set time-scale. A pathway is divided into time intervals during which specific goals and expected progress are defined, together with appropriate investigations and treatment. A pathway reflects the activities of a multidisciplinary team and can incorporate established guidelines and evidence-based medicine. It is usually unique to the institution in which it was developed. The pathway forms part of the clinical record of every patient. All variations from the pathway are documented, and the reasons for the variations analysed. Solutions are developed to address the causes of potentially avoidable variation, and the pathway is revised to incorporate these improvements. Integrated Care Pathways provide a powerful audit tool, as all aspects of the process and outcome of clinical practice can be constantly monitored. Variations from set standards are minimized, and improvements are rapidly incorporated into routine practice and subsequently re-evaluated. [References: 26]

319.    Kirton, O. C., Civetta, J. M., & Hudson-Civetta, J. (1996). Cost effectiveness in the intensive care unit. [Review] [54 refs]. Surgical Clinics of North America, 76(1), 175-200.
Abstract: Effective policies to reduce true costs will require integrated information systems and demand behavioral changes from providers. A congenial environment must be created among medical educators, providers, vendors, and consumers if cost reduction is to be accomplished without compromising quality or access to critical care services. Physicians should do everything they believe may be of benefit for their patients, but we have an obligation to educate the public about the limitations of our art and the fact that "doing everything" is not always best for the patient or the grieving family. A significant method of controlling ICU costs is closely monitoring which patients are admitted and when they are discharged. Laboratory tests represent a source of cost reduction, and physicians must learn to order specific tests and not simply a battery of tests which includes the actual test desired. Limits should be placed on the tests that are ordered in terms of number and frequency. Improved efficiency of the utilization of resources should improve the care of our patients. The largest budget item of any or most critical care units is nursing; it is paramount that this essential and invaluable resource be utilized in a cost-effective manner. Diminishing unnecessary activity will both decrease complications and have salutary effects. Having more time to be with patients and their families will decrease our sense of failure and fulfill the important goal of caring. Physicians and nurses can return to thinking, assessing, and decision making instead of frenetically ordering, reacting, and intervening, which, we believe, accurately describes informational overload created by undue emphasis on high technology. In this way, we can respond to Fuch's exhortation that "physicians consider the possibility of contributing more by doing less." In responding, however, we must never forget that the societal, not merely the economic impact of medical care, is our principal consideration. We must first contribute more by achieving a greater understanding of the medical care process. Only then can we know how to do less at the bedside. We can and must distinguish between costly and high-quality care--they are not necessarily synonymous. [References: 54]

320.    Horne, M. (1996). Involving physicians in clinical pathways: an example for perioperative knee arthroplasty. Joint Commission Journal on Quality Improvement, 22(2), 115-24.
Abstract: BACKGROUND: At Stanford University Hospital, attempts to improve the case management program led to the development of clinical paths, a multidisciplinary case management tool. Successful design and implementation of clinical paths depend on physician leadership. However, since physicians are trained to function independently and to treat each clinical problem as unique, they tend to resist attempts to have them follow clinical paths. Strategies to get physicians who perform the same clinical procedure to agree with each other on a sequence of common interventions had to be developed. Clinical paths define the expected processes of care and therefore allow for the introduction of continuous quality improvement (CQI) into the clinical arena. A structure had to be developed for the effective use of pathways in a CQI framework, and physicians had to be encouraged to function as CQI leaders. EXAMPLE: Description of the design of a perioperative knee arthroplasty pathway demonstrates the steps needed for successful physician involvement in pathway design and its integration into clinical CQI. CONCLUSIONS: With sensitive facilitation, physicians can become productive leaders of the design of clinical paths, and when they learn the benefits of improved efficiency, outcomes, and costs their involvement becomes self-sustaining. A quality improvement group led by physicians to develop the pathway after implementation can mark the beginning of clinical CQI implementation

321.    Grady, G. F., & Wojner, A. W. (1996). Collaborative practice teams: the infrastructure of outcomes management. [Review] [12 refs]. AACN Clinical Issues, 7(1), 153-8.
Abstract: Collaborative practice teams consist of interdisciplinary providers who are charged with the process of implementing and refining an outcomes management program within a targeted population. Collaborative practice teams work under the assumption that clinical quality enhancement through practice standardization decreases care fragmentation, resulting in improved physiologic, psychosocial, and financial outcomes. Collaborative practice team members identify best practice through the implementation and testing of interdisciplinary interventions. Represented on a critical pathway, these practices are evaluated toward achievement of defined population outcomes. In this article, the authors review the process of collaborative practice team formation, expected pitfalls and barriers to effective collaboration, and the work accomplished by a collaborative practice team. [References: 12]

322.    Del Togno-Armanasco, V. (1996). Case management: the promise, the process, and the vision. Aspens Advisor for Nurse Executives, 11(5), 7-8.

323.    Campion, F. X., & Rosenblatt, M. S. (1996). Quality assurance and medical outcomes in the era of cost containment. [Review] [35 refs]. Surgical Clinics of North America, 76(1), 139-59.
Abstract: Market forces are driving health care organizations to "prove" quality while diminishing costs. Payers for health care, led by large employers and insurance companies, are demanding clinical, financial, and satisfaction outcomes from providers. To meet the challenge, traditional quality assurance based on inspection and rooting out "bad apples" is rapidly being replaced by the industrial engineering principles of continuous quality improvement. A philosophical shift is occurring from a focus on episodes of care delivered by physicians to the delivery of processes of care by teams of health care personnel. We are seeing a shift in emphasis from a fascination with intensive care delivered to sick patients to cost-effective preventive services delivered to populations of well patients. The locus of care delivery is moving from inpatient hospitals to ambulatory clinics and home care. The need for this information is leading to innovation in computer systems and health care organizations. New partnerships are emerging between physicians, nurses, and hospitals. Traditional oversight bodies including the JCAHO and the HCFA-sponsored PROs are restructuring to meet these new demands. New organizations such as the National Committee on Quality Assurance and state governmental agencies are being established to fill the perceived void. Individual surgeons have begun to receive performance data on their individual and group practices. Professional societies have collaborated in the development of clinical guidelines and outcomes data bases. This massive reorganization will take several more years to play out. With careful development it has the potential to dramatically improve patient care through the efficient application of new scientific knowledge and the sustained flow of information back to physicians and patients. [References: 35]

324.    Burgum, M. (1996). A new path to documentation. Australian Nursing Journal, 3(7), 38-40.

325.    Ballard, D. J. (1996). Hips and knees: state of evidence regarding effectiveness of quality improvement interventions in orthopedic surgery [editorial]. Mayo Clinic Proceedings, 71(2), 208-10.

326.    Morrall, K. (1996). Coordinated care. Paving the road to Medicare savings. Hospitals & Health Networks, 70(2), 43.

327.    DeMott, K. (1996). Pa. hospital cuts time spent on joint replacement rehab. Healthcare Systems Strategy Report, 13(2), 1-4.

328.   Newton, M., Grant, E., Shea, L., & Napier, J. C. (1996). Critical pathway's effect on cystectomy outcomes. Journal of Urological Nursing, 15(1), 1204-15.

329.    Hughes, K. H., & Ashby, C. (1996). Essential components of the short-term psychiatric unit. Perspectives in Psychiatric Care, 32(1), 20-5.
Abstract: TOPIC. How nurses can meet the priority needs of the acute care clients during inpatient psychiatric hospitalizations that average five days. PURPOSE. To assist acute care nursing staff in reorganizing their caregiving to maximize therapeutic gains of clients in a minimum period of time. SOURCE. Personal experience. CONCLUSION. Success in the short-term unit depends not only on the ability of nurses to stabilize clients in crisis, but also on their ability to provide linkage with aftercare services so the therapeutic process can be continued.  (4 ref)

330.    Fortune, G., Elder, S., Jaco, D., Bentivegna, P., Luebbering, T., & Boechler, M. (1996). Opportunities for improving the care of patients with community-acquired pneumonia. Clinical Performance & Quality Health Care, 4(1), 41-3.
Abstract: In Missouri, community-acquired pneumonia is the second leading cause of hospital admission in the Medicare population. Analysis of 1993 discharges revealed that more than 18,000 Medicare patients were admitted to acute care hospitals with a principal diagnosis of pneumonia. Statewide, the case fatality rate for these admissions was 9.6%, with an average length of stay of 8.2 days. Under the auspices of Medicare's Health Care Quality Improvement Program, the Missouri Patient Care Review Foundation (MPCRF) collaborated with five hospitals in the state on a project to enhance the outcomes and quality of care for patients admitted with community-acquired pneumonia. Narrowing the focus to bacterial community-acquired pneumonia, the five hospitals agreed to collect data, for a specified period, on each Medicare patient admitted with this diagnosis. The hospitals were encouraged to implement recommended critical pathways and guidelines for the initial management and treatment of community-acquired pneumonia. MPCRF assumed responsibility for data management activities for the project as well as production of feedback reports that were shared routinely with the hospitals. Although evaluation of the project continues, preliminary analysis of claims data for admissions occurring after process changes were implemented indicates that there has been improvement in the two outcome measures, patient mortality and length of stay. These results suggest that monitoring of key process indicators, coupled with ongoing analysis and feedback, has potential for facilitating positive change in the quality of care for patients with community acquired pneumonia.  (Abstract by: Author)

331.    Carpenito, L. J. (1996). Critical pathways: a wolf in sheep's clothing? [editorial]. Nursing Forum, 31(1), 3-5.

332.    Velasco, F. T., Ko, W., Rosengart, T., Altorki, N., Lang, S., Gold, J. P., Krieger, K. H., & Isom, O. W. (1996). Cost containment in cardiac surgery: results with a critical pathway for coronary bypass surgery at the New York hospital-Cornell Medical Center. Best Practices & Benchmarking in Healthcare, 1(1), 21-8.
Abstract: PURPOSE: A multidisciplinary project was undertaken at The New York Hospital-Cornell Medical Center to develop critical pathways for open-heart surgery to help reduce cost, shorten hospital length of stay (LOS), and streamline patient care. METHODS: A critical pathway for elective coronary artery bypass grafting instituted on March 1, 1995, was developed through a cooperative effort involving surgeons, anesthesiologists, nurses, social workers, physical therapists, nutritionists, and patient case managers. Prospective data collected on consecutive patients forming a critical pathway group (n = 114) over a 6-month period were compared with retrospective data on consecutive patients forming a cohort group (n = 382) who underwent elective coronary artery bypass grafting in 1994. RESULTS: The critical pathway group of patients experienced a significantly shorter total hospital LOS (7.7 +/- 2.3 days vs 11.1 +/- 6 days, p < 0.0001) and shorter intensive care unit LOS (1.5 +/- 0.9 days vs 2.0 +/- 2.8 days, p < 0.0001). Direct costs were computed by use of hospital charges multiplied by the Medicare cost-to-charge ratio. Mean hospital direct cost (ancillary resources) was $1181 lower in the critical pathway group when compared with the control group (p < 0.0001). The postoperative mortality and readmission rates were similar for the two groups of patients. CONCLUSIONS: The ongoing analysis of cost, LOSs, and outcomes has made possible a process of continuous quality improvement on the cardiothoracic service in which further areas for improvement are identified and studied. The use of a critical pathway for elective coronary artery bypass grafting at our institution significantly reduced hospital LOS and direct costs while maintaining the overall quality of patient care

333.    Stiller, A. L., & Brown, H. N. (1996). Case management: implementing the vision. [Review] [14 refs]. Nursing Economics, 14(1), 9-13.
Abstract: Case management is a strategy for restructuring the health care delivery system. The system requires critical planning and implementation steps to achieve quality care at reduced cost. [References: 14]

334.    Southwick, K. (1996). Disease management. To partner or not to partner? Healthcare Forum Journal, 39(1), 32-40.

335.    Smith, R. J. (1996). Buying more time in less time: case management and bone marrow transplantation. Case Manager, 7(1), 77-8,80-83.

336.    Schmer, C. (1996). Field notes. A working relief. HT: The Magazine for Healthcare Travel Professionals, 3(4), 42.

337.    Rosenstein, A. H., & Moore, K. (1996). Using data to improve clinical effectiveness: an orthopedic case study. Journal of Healthcare Resource Management, 14(1), 15-22.

338.    Oberer, D., & Auckerman, L. (1996). Best practice: clinical pathways for uncomplicated births. Best Practices & Benchmarking in Healthcare, 1(1), 43-50.
Abstract: BACKGROUND: A level II hospital with births exceeding 2000 annually was challenged by managed care companies to develop high-quality, cost-effective, and clinically efficient obstetric and newborn care under the constraints of a reduced length of stay. METHODS: As a result of the challenge, clinical pathways were initiated for vaginal and cesarean section births and for normal newborns. RESULTS: Successful implementation of the clinical pathways has decreased the average length of stay for uncomplicated deliveries from 2.02 to 1.67 days and for normal newborns from 1.99 to 1.43 days. CONCLUSIONS: Data from quality outcome indicators that measure the rate of occurrence of emergency department admissions or hospital readmissions for either mother or newborn within 14 days of birth reveal no increase in either variance since the clinical pathways were implemented

339.    Marelli, T. M., & Hilliard, L. S. (1996). Treating patient ulcers. Home Care Provider, 1(1), 41-3.

340.    Comried, L. A. (1996). Cost analysis: initiation of HBMC and first CareMap. Nursing Economics, 14(1), 34-9.
Abstract: The start-up costs incurred when instituting Hospital Based Managed Care (HBMC) and using CareMaps in a large mid-western teaching hospital are analyzed. The complete cost analysis of developing the first CareMap, Cesarean Section, is included. Cost analysis of an additional CareMap, Normal Vaginal Delivery, is available for comparison for the developmental phase of the CareMap. The CareMaps were designed by the same multidisciplinary team though 18 months apart

341.    Wojner, A. W. (1996). Outcomes management: driving enhancement of interdisciplinary practice with outcomes research. [Review] [15 refs]. Seminars in Perioperative Nursing, 5(1), 3-11.

342.    Venner, G. H., & Seelbinder, J. S. (1996). Team management of congestive heart failure across the continuum. Journal of Cardiovascular Nursing, 10(2), 71-84.
Abstract: Despite an increased incidence of congestive heart failure and frequency of hospital admissions for the Medicare population, there is little information available on improving outcomes for these patients. As changes in health care lead toward capitation, efficient care with limited use of expensive inpatient hospital resources is a necessity. The coordination of three critical components--inpatient, outpatient, and home care--can lead to positive outcomes in terms of functional capacity changes, length of stay, readmission rates, patient self-care knowledge, and patient satisfaction

343.    Underwood, R. T. (1996). Developing critical pathways. Ot Practice, 1(1), 23-26.

344.    Prophet, S., & Bryant, G. (1996). Growing demand for accurate coded data in new healthcare delivery era. Journal of Ahima, 68(1), 42-7; quiz 49-50.

345.    Poole, P., & Johnson, S. (1996). Integrated care pathways: an orthopaedic experience. Physiotherapy, 82(1), 28-30.
Abstract: Integrated care pathways (ICPs) are both a case management and clinical audit tool in one. Ashford Hospital started using ICPs in 1992, and found they helped to raise the quality of patient care, through improved teamwork and co-ordination of care delivered by all the different disciplines involved with orthopaedic elective surgery. This paper explains what ICPs are, and how they are used. We highlight the difficulties encountered, together with the benefits and outcomes of using them in one typical orthopaedic unit.  (2 ref)

346.    Palmer, J. S., Worwag, E. M., Conrad, W. G., Blitz, B. F., & Chodak, G. W. (1996). Same day surgery for radical retropubic prostatectomy: is it an attainable goal? [see comments]. Urology, 47(1), 23-8.
Notes: Comment in: Urology 1996 Oct;48(4):660-1
Abstract: OBJECTIVES. Economic forces are stimulating a re-evaluation of various management strategies. Recent critical pathways for radical prostatectomy have resulted in reduced length of stay to as low as 2.9 days. METHODS. The time in the operating room and recovery room, average blood loss, length of hospitalization, patient charges, and estimated hospital costs were compared for 20 patients undergoing radical prostatectomy up to 1 year before and for 27 men after initiation of a critical pathway. Under the protocol, patients receive an education booklet and preoperative teaching in preparation for early discharge and an epidural for anesthesia. An anonymous questionnaire was mailed to all patients treated by the pathway after catheter removal. RESULTS. The new pathway resulted in a significant reduction in average time in the operating room (3.7 +/- 0.4 hours versus 4.9 +/- 1.2 hours), estimated blood loss (1204 +/- 527 cc versus 1948 +/- 740 cc), and length of hospitalization (1.7 +/- 0.6 days versus 4.6 +/- 1.5 days). In addition, patient charges and hospital costs were reduced by 32% and 35%, respectively. Thirty-seven percent of the study group was discharged after 1 night compared with 0% in the group treated before the pathway was initiated. Forty-one percent of the study group was not transfused and did not donate blood. Outcome surveys completed by 25 of 27 study patients revealed an overall satisfaction of 96% with 0 of 10 patients who were discharged after one night indicating they would have preferred to be hospitalized longer. CONCLUSIONS. Conventional management of men undergoing radical prostatectomy can be safely modified while preserving patient satisfaction without increasing morbidity. Avoiding peripheral narcotics and emphasizing preoperative teaching has enabled us to reduce length of stay greatly, with same day discharge now an attainable goal

347.    Oetker, D., & Cole, C. (1996). Improving the outcome of emergency department patients with a chief complaint of chest pain. Journal of Nursing Care Quality, 10(2), 58-74.
Abstract: Preliminary data developed by the Health Care Financing Administration under its pilot cooperative cardiovascular screening project indicate that 50 percent of Medicare heart attack patients arriving in emergency departments who are appropriate for thrombolytic therapy do not receive it within the time period specified by the American College of Cardiology. Indicators developed for quality assurance monitoring and evaluation of a hospital emergency department prompted closer review of some cases. It was determined that a critical outcomes team using the principles of total quality management and the FOCUS-PDCA models should be empowered to deal with these issues. Through this process, the need for the development of a chest pain center at the hospital was identified and supported

348.    Marks, P. A., Richon, V. M., & Rifkind, R. A. (1996). Cell cycle regulatory proteins are targets for induced differentiation of transformed cells: Molecular and clinical studies employing hybrid polar compounds. [Review] [152 refs]. International Journal of Hematology, 63(1), 1-17.
Abstract: Considerable progress has been made toward elucidating the pathway of induction of terminal differentiation of transformed cells by hybrid polar compounds such as hexamethylene bisacetamide (HMBA). HMBA alters factors controlling G1-to-S phase transition, leading to G1 arrest and inhibition of DNA synthesis. Among the inducer-mediated changes, suppression of cyclin-dependent kinase cdk4, which may be required for phosphorylation of the retinoblastoma protein pRB and perhaps p107, is critical in the pathway of terminal differentiation. HMBA induces an increase in the level of p21 which inhibits cyclin-dependent kinase activity and, in turn, may cause cells to arrest in G1. p107 complexes with transcription factor E2F, which may alter E2F-dependent gene transcription. the relationship of the inducer-mediated changes in cyclins, cdks, cyclin-cdk inhibitors and transcription factors to the expression of differentiation-specific genes has not yet been established. The hybrid polar compounds are potent inducers of differentiation of a wide variety of transformed cells. HMBA has been shown to induce differentiation of neoplastic cells in patients. A second generation of hybrid polar compounds have been synthesized which are up to 1000 fold more potent than HMBA on a molar basis as inducers of murine erythroleukemia (MEL) cells and other transformed cells in vitro. The potential of these compounds as clinically useful inducers of differentiation of cancer cells is under study. [References: 152]

349.    Lowe, A. (1996). Reducing variation in patient care: nursing responds to capitation. Journal of Nursing Administration, 26(1), 14-20.
Abstract: As managed care and capitation methods of payment become more common to hospitals, a strategy to improve quality and reduce costs is introduced in response to these new pressures. Nursing leaders must take the initiative and respond to these changes by reducing the variations in patient care. The author describes seven initiatives undertaken by the nursing leaders of The St. Joseph Healthcare System in Albuquerque, New Mexico, during a 3-year period. The success of these initiatives and their universal application is discussed.  (10 ref)

350.    Jesurum, J. T., Alexander, W. A., Anderson, J. J., & Houston, S. (1996). Fast Track recovery after aortocoronary bypass surgery: early extubation and intensive care unit transfer. Seminars in Perioperative Nursing, 5(1), 12-22.
Abstract: Fast Track is a practical method of delivering care to aortocoronary bypass (ACB) patients with minimal risks to the patients or their care providers. A prospective study designed by an interdisciplinary practice team will evaluate the effects of an accelerated recovery program on clinical and financial outcomes of ACB patients. Essential components of the accelerated recovery program include early extubation, accelerated activity, and appropriate patient selection. Preliminary results on early extubation are discussed

351.    Ebener, M. K., Baugh, K., & Formella, N. M. (1996). Proving that less is more: linking resources to outcomes. Journal of Nursing Care Quality, 10(2), 1-9.
Abstract: Advocates of inpatient managed care employing clinical pathways are confident that this patient management strategy reduces cost while promoting optimal patient outcomes. Other health care professionals are concerned that cost reductions place patients at higher risk for adverse health events. Research is needed to demonstrate the true impact of cost-containment strategies on clinical outcomes. The article describes a study in progress comparing patients conventionally managed by their physicians with similar patients whose overall management involved a nurse case manager. This study explores the issue of resource costs that can be linked to clinical and financial outcome measures

352.    Dye, L., & Langford, A. (1996). Lumbar discectomy procedure cuts 5-day LOS to 1 day. Hospital Case Management, 4(1), 7-10.

353.   Chowanec, G. D. (1996). The fall and rise of TQM at a public mental health hospital. Joint Commission Journal on Quality Improvement, 22(1), 19-26.
Abstract: BACKGROUND: Public mental health care is undergoing a period of fundamental change as it attempts to adapt to an environment characterized by increasing fiscal constraints, the need to demonstrate effectiveness of services, and consumer empowerment. Total quality management (TQM) provides a framework that enables mental health care to meet these demands. The author provides his perspective on a public, multipurpose psychiatric hospital's (Georgia Regional Hospital at Augusta) experience in making the transition from quality assurance to TQM. WITHOUT GOALS YOU CANNOT IMPROVE: Successful implementation of TQM rests on clinical staff's viewing TQM as a useful mechanism for achieving agreed-on patient/customer goals. Staff cannot simply do what they have been doing, but now do it better; there needs to be an understanding of what "better" means. TQM'S INTRODUCTION AND REINTRODUCTION: When first introduced in 1992, TQM was viewed by staff as the latest variant of quality assurance--and was therefore unsuccessful. When reintroduced in 1993, TQM contributed to the development of a psychosocial rehabilitation program. The staff's active involvement in establishing patient-specific goals was critical to the program's success. PERFORMANCE IMPROVEMENT: The hospital's Performance Improvement Committee has spearheaded the monitoring of treatment programs and the development of critical paths. In developing critical paths, the treatment team sets goals for patients' improvement both within the hospital and postdischarge and for treatment processes. SUMMARY AND CONCLUSIONS: The keys to a successful TQM program are effective leadership, a clear organizational mission, customer-oriented performance goals, staff empowerment, and the application of the scientific method to the workings of the organization

354.    Bultema, J. K., Mailliard, L., Getzfrid, M. K., Lerner, R. D., & Colone, M. (1996). Geriatric patients with depression. Improving outcomes using a multidisciplinary clinical path model. Journal of Nursing Administration, 26(1), 31-8.
Abstract: Clinical pathways define multidisciplinary staff members' responsibilities, time lines, and patient outcomes. Although medical and surgical care settings frequently use them to improve quality, clinical, and fiscal outcomes for specific patient populations, staff members of psychiatric care settings have been hesitant to use clinical pathways because psychiatry emphasizes patient individuality. The authors describe the development and implementation of a psychiatric clinical pathway for geriatric patients with depression and identify common multidisciplinary interventions and a pattern of outcomes over the course of treatment for these patients. They also delineate quality and fiscal outcomes and future directions. Implementation of the pathway has been successful, and the development and implementation processes have applicability to other patient populations and care settings

355.    Bazzoli, F. (1996). Disease management. Putting the pieces together. Health Data Management, 4(1), 28-32, 34, 36-37.
Abstract: Many providers are launching disease management programs to improve the cost-efficiency and quality of health care. The hot new buzzword encompasses many components, including utilization management, patient education and treatment protocols. Savvy health care organizations are devising ways to take full advantage of information technology when implementing disease management programs.  (Abstract by: Author)

356.    Zander, K. (1996). The early years: the evolution of nursing care management . In D. Flarey (Ed.), Handbook of nursing case management: health care delivery in a world of managed care (pp. 23-45). Gaithersburg, MD: Aspen Publishers.

357.    Windle, P. E., & Houston, S. (1996). Documentation to achieve patient outcomes through critical pathways . In D. Flarey (Ed.), Handbook of nursing case management: health care delivery in a world of managed care (pp. 100-135). Aspen Publishers: Gaithersburg, MD.

358.    Verhey, M. P., Kotzer, A. M., Miller, K. L., Bostrom, J., Crawford-Swent, C., Lonhart, N., Verhey, M. P., & Ferretti, C. K. (1996). Abstracts of WIN podium presentations. Administration in quality nursing management... the 10th Annual WIN Assembly/29th Annual Communicating Nursing Research Conference, "Advancing Nursing through Research, Practice, and Education," was held April 25-27, 1996, in Denver, Colorado. Communicating Nursing Research, 29, 19-23.

359.    Uttermohlen, D. M. (1996). Selling high quality and low cost: market conditions and successful quality improvement projects. Journal of the Society for Health Systems, 5(2), 73-81.
Abstract: Many potentially useful health care improvement projects fail to achieve much improvement. Even a technically excellent project can fail because, under certain conditions, economic factors in the health care market do not support high quality and low cost. Most health care markets evolve from the traditional fee for service market through a consolidation phase into risk shared market. At each phase, payment mechanisms will support specific quality and productivity improvement projects and discourage others. For example, the implementation of critical paths/clinical protocols is not supported until the majority of payers pay a fixed cost per illness or covered life. Prior to that point, loss of income for the hospital and/or physicians will inhibit successful implementation. Maximum quality and productivity improvements outcomes can be achieved with minimum efforts when project leaders understand the maturity of their organization's market, and strategic needs. This paper will review the types of payment systems (fee for service, discounted fee for service, and risk shared payments) and identify the types of projects that maximize benefit to the stakeholders involved

360.    Trella, B. (1996). Integrating services across the continuum: the challenge of chronic care . In E. Cohen (Ed.), Nurse case management in the 21st century (pp. 87-104). St. Louis, MO: Mosby-Year Book.

361.    Stark, J., Litto, L., Connor, J., & Hayes, J. (1996). Redesign in an outpatient hemodialysis unit: the implementation of team case management. In S. Blancett (Ed.), Case studies in nursing case management: health care delivery in a world of managed care (pp. 294-312). Gaithersburg, MD: Aspen Publishers.

362.    Schubert, T. (1996). [Analysis of interference effects in simultaneous processing of 2 problems]. [German]. Zeitschrift Fur Experimentelle Psychologie, 43(4), 625-56.
Abstract: The aim of this investigation was to analyze dual-task interference in the so called Psychological Refractory Period (PRP) paradigm. In this paradigm subjects have to carry out two choice reaction tasks that overlap in time. A well known result is that reaction time on task 2 (Rt2) increases with decreasing overlap of the two tasks. Thereby reaction time on task 1 is described to be independent of the size of overlap (Rt 1). Usually, this result is explained by the assumption of a PRP which arises in processing of task 2, when serial processing is ongoing in both tasks. It was asked, 1.) whether the PRP is located before or after response selection in the first task and 2.) how the second task influences first task processing. In the experiment subjects had to carry out two choice reaction tasks together. In different conditions the difficulty of response selection in task 2 was systematically increased by varying the number of response alternatives (0, 1, 2, 3). Difficulty of response selection in task 1 was held constant. Overlap between both tasks was varied. This experimental design allows different hypotheses about the sources of interference in both tasks to be examined by use of Schweickert's Critical Path Technique (Schweickert, 1983). Contrary to the results of Karlin and Kestenbaum (1968) the effects of number of response alternatives and size of overlap on Rt2 indicate a localization of the PRP before response selection. The results support models which assume a serial processing in response selection (Welford, 1952). They are contrary to models of parallel processing in this stage (Keele, 1973). The influence of the number of alternatives in task 2 on Rt 1 can be explained by a mechanism of grouping both motor responses

363.    Pelfrey, S., & Wesley, M. L. (1996). Cost savings and financial analysis of case management models . In D. Flarey (Ed.), Handbook of nursing case management: health care delivery in a world of managed care (pp. 362-78). Gaithersburg, MD: Aspen Publishers.

364.    Pearson, K., & Meyer, H. (1996). Waiting times: the search for equitable solutions. Case study: Mater Misericordiae Adult Public Hospital Continuum of Care Model. Australian Health Review, 19(4), 93-9.
Abstract: For the survival of any health care organisation, evidence-based practice is fundamental, particularly in today's economic climate. The Mater Misericordiae Adult Public Hospital in Brisbane is committed to providing a flexible health care system that is responsive and accountable to the needs of the customers. As part of the Mater's continuous quality improvement program, a Continuum of Care Service Delivery Model was developed. This model comprises many innovative clinical management systems which have evolved over recent years. Clinical pathways, care management, pre-admission clinics, variance management and evidence-based practice are core components of the model.  (Abstract by: Author)

365.    Newlin, P. R., Gibbs, B. A., Lonowski, L. R., & Meyer, P. J. (1996). Spanning the continuum of care: managing a geriatric client with a CVA. In S. Blancett (Ed.),  Case studies in nursing case management: health care delivery in a world of managed care (pp. 354-68). Aspen Publishers: Gaithersburg, MD.

366.   Newby, L. K., & Califf, R. M. (1996). Identifying patient risk: The basis for rational discharge planning after acute myocardial infarction. Journal of Thrombosis & Thrombolysis, 3(2), 107-115.
Abstract: Variations in the management of patients with chest pain and acute myocardial infarction (MI) can significantly affect hospital length of stay and cost. Risk stratification of such patients, combined with data about effective therapies, provides the basis for developing rational guidelines for patient care that can improve efficiency while maintaining quality of care. Such standardized management approaches are often referred to as pathways or CareMaps. To be most effective in guiding hospital course and early discharge planning, risk stratification strategies must be applied early in a patient's course with continuous updating. The process of identifying risk in a patient with acute chest pain occurs in two segments: assessing the risk of acute MI at presentation, and subsequently assessing the morbidity and mortality risk of patients diagnosed with acute MI. Identification of patient risk at presentation has been the subject of intense investigation. The history, physical exam, initial electrocardiogram, and cardiac enzymes are the mainstays of the process, but because of inherent weaknesses in this approach (> 25% of acute MIs missed at the initial screening), several risk stratification models have been developed. To date these models have not been widely employed, however. Very sensitive early cardiac markers, such as troponin T, and the use of diagnostic echocardiography or cardiolite perfusion imaging during pain are also being investigated. Chest pain observation units are an alternate strategy and have obviated the need to admit many low- to moderate-risk chest pain patients. In these protocol-driven units, continuous physiologic monitoring and serial cardiac enzymes and electrocardiography over a 9-12 hour period refine the risk assessment. For the majority who 'rule out,' the risk of subsequent MI or death is very low. Cost savings due to reduced length of stay and more efficient resource utilization are 63-76% compared with conventional ward or cardiac care unit management. For patients with acute MI, baseline characteristics, complications, and laboratory and diagnostic testing help define the risk of morbidity and mortality and guide management through the immediate post-MI phase and long term. Many models incorporating these features have been proposed for risk stratification after acute MI, and they have implications for both timing of discharge and necessary diagnostic testing. Savings by employing risk stratification to guide hospital course and discharge planning could be 30-44% in some patient groups. In conclusion, risk stratification models can facilitate early discharge planning, potentially reducing hospital stay, improving resource utilization, and reducing costs.

367.    Myers, A. H., Palmer, M. H., Engel, B. T., Warrenfeltz, D. J., & Parker, J. A. (1996). Mobility in older patients with hip fractures: examining prefracture status, complications, and outcomes at discharge from the acute-care hospital. Journal of Orthopaedic Trauma, 10 (2), 99-107.
Abstract: The purpose of this study was to examine the relationships among prefracture status, development of complications, mobility outcomes at discharge, and disposition at discharge. We singled out a case series of consecutive noninstitutionalized elderly persons hospitalized for hip fracture (ICD 820.0-820.9) at two Baltimore hospitals during 1992-1993. Data were abstracted from the medical records for the following variables: sociodemographic information, prefracture status, selected medical conditions, injury and surgical treatment, complications, functional mobility and assistance needed at discharge, and disposition. Factors associated with four complications were identified from multiple logistic regression analyses. (a) Prefracture needs for assistance with activities of daily living (ADL), and age > or = 80, were associated with the development of pressure ulcers. (b) Male gender and prefracture urinary incontinence (UI) were associated with pneumonia. (c) Prefracture UI and weight-bearing status were associated with UI after removal of an indwelling catheter. (d) Age > or = 80 was associated with urinary retention. The amount of assistance needed for mobility tasks at discharge was associated with prefracture need for assistance with ADLs, gender, weight-bearing status, and hospitals with shorter lengths of stay and fewer physical therapy sessions. Patients who were older and had shorter lengths of stay and less physical therapy were more likely to go to another health facility than directly home. Prefracture status (ADL, prefracture UI) was significantly associated with the development of complications. Prefracture needs for assistance with ADL and complications were associated with mobility outcomes at discharge. These prefracture factors have an effect on outcomes and need to be addressed in the development of critical pathways for case treatment. Specific protocols for subgroups of patients may need to be designed and evaluated

368.    Miller, K., & Eliastam, M. (1996). Developing a path for lifetime wellness. In Toward an electronic patient record '96: proceedings, volume two.    (pp. 464-465). Newton, MA: Medical Records Institute.

369.    Miller, J., Sater, K., & Mazur, L. (1996). Impact of a clinical pathway in the care of febrile infants. Ambulatory Child Health, 2(2), 123-127.
Abstract: Objective. To assess the efficiency of care of a clinical pathway for febrile infants. Design. Before and after implementation of a clinical pathway. Setting. Hermann Children's Hospital in Houston, Texas. Patients. Infants less than 28 days of age with a rectal temperature greater than 38 [degree] C. Main outcome measures. Time to admission to the pediatric unit from the emergency center, length of hospital stay, and total hospital costs. Results. Significant decrease in total hospital costs, $3176 vs. $2255, and a trend towards decreased time to admission to the pediatric unit from the emergency center, 4.9 vs. 3.9 hours. Conclusions/implications for practice. The implementation of a clinical pathway for infants with suspected sepsis resulted in significant savings. The time from presentation to the emergency center and admission to the pediatric unit was also significantly shortened.

370.    McCloskey, J. C., & Bulechek, G. M. (1996). Critical Path Development (Iowa NIC) . In Nursing interventions classification (NIC): Iowa intervention project  (2 ed., ). St. Louis, MO: Mosby-Year Book.
Abstract: SCOPE NOTE: Constructing and using a timed sequence of patient care activities to enhance desired patient outcomes in a cost efficient manner. Use only as a specific Iowa Nursing Interventions Classification. Copyright (c) 1996, Mosby-Year Book, Inc. CINAHL EDITORIAL SEARCH SUGGESTION: The term CRITICAL PATH DEVELOPMENT (IOWA NIC) is used for indexing when articles specifically concern the term or research about the term. For citations that concern the general topic or topics related to the term, consider searching the subject heading: CRITICAL PATH.

371.    Maxwell, M., Kennedy, T., & Spours, A. (1996). Clinical benchmarking: results into practice. International Journal of Health Care Quality Assurance, 9(4), 20-3.
Abstract: Describes the way benchmarking data are used in a district general hospital to influence clinical practice. Wirral Hospital Trust is a site for the Electronic Patient Record Project; as such there is a large amount of patient based data available for research and internal benchmarking. Includes working examples of internal benchmarking which have been used by both clinicians and hospital management to improve hospital effectiveness. Discusses the ways in which this information is being used to develop initiatives such as clinical pathway development.  (Abstract by: Author)

372.    Mateo, M. A., Newton, C. L., & Kanatas, K. K. (1996). Developing and implementing critical paths in case management . In D. Flarey (Ed.), Handbook of nursing case management: health care delivery in a world of managed care (pp. 80-99). Gaithersburg, MD: Aspen Publishers.

373.    Marrelli, T. M., & Hilliard, L. S. (1996). Home care and clinical paths: effective care planning across the continuum. St. Louis, MO: Mosby-Year Book.

374.    Lee, T. H. (1996). Emergency department observation units: Has the time come? Journal of Thrombosis & Thrombolysis, 3(3), 257-261.
Abstract: Background: Economic pressures for efficiency in health care have led to the need for new strategies for the care of patients with acute chest pain. Methods: Chest pain observation units have been developed in many hospitals and are widely considered to have the potential to provide rapid and safe evaluations for low-risk patients with acute chest pain. Critical pathways are also an increasingly used strategy for the management of this patient population. Results: Available data suggest that chest pain observation units can decrease 6 month resource utilization compared with patients admitted to traditional sites of care. However, the potential exists for these units to increase resource utilization by encouraging admissions to the hospital of patients who otherwise would have been discharged directly home. Conclusions: Chest pain observation units appear to be an important innovation for the care of patients with a low risk for acute myocardial infarction. Use of guidelines for these units may permit true increases in efficiency without compromising quality.

375.    Konety, B. R., Painter, L., & Bahnson, R. R. (1996). A cost containment strategy for radical retropubic prostatectomy: Results from implementation of a clinical pathway program. Urologic Oncology, 2(3), 80-87.
Abstract: Health care costs from the management of prostate cancer are estimated at $1.5 billion per year. As the number of radical prostatectomies being performed increases, a simultaneous rise in these costs can be expected. However, diminishing resources and the expanding managed care environment necessitate measures to curtail and even reduce these inflationary trends in health care expenditure. With this in mind, we established a collaborative clinical pathway for patients undergoing radical retropubic prostatectomy at our institution. The goals of the pathway were to reduce patient costs and hospital stay and to promote efficient use of resources for the procedure. We studied 71 patients who underwent radical retropubic prostatectomy and were managed according to the pathway during the first year of its implementation (July 1994 through July 1995). Outcome variables for these patients were compared with those of a group of 65 patients who underwent an identical procedure during the previous year (July 1993 through June 1994) before implementation of the pathway. Outcome parameters that were compared included hospital charges, length of stay (LOS), operating room (OR) time, units of packed red cells transfused, morbidity, and mortality. The overall hospital charges since implementation of the pathway decreased by 17.2% when corrected for inflation (p <= 0.006). LOS also decreased from a mean of 6.4 days to 5.2 days. There was no significant change in OR time. Overall complications remained unaffected (12.3% vs 12.6%). Based on these results, we conclude that establishment of an individualized, procedure-oriented clinical pathway for patients undergoing radical retropubic prostatectomy can result in significant reduction in patient costs without appreciable effect on morbidity and mortality.  [References: 20]

376.    Knight, G. (1996). Project management for health care professionals. In  Proceedings of the 1996 Annual HIMSS Conference, March 3-7, 1996, Atlanta, Georgia, Volume 1  (pp. 341-352). Chicago, IL: HIMSS.

377.    Kelso, S. W., & Myers, J. E. (1996). Integrating medication management into the electronic patient record. In  Toward an electronic patient record '96: proceedings, volume two  (pp. 62-71). Newton, MA: Medical Records Institute.
Abstract: Presented is an approach to consolidating patient medication data and integrating that data into the electronic patient record.  True medication management involves more than just automated prescription writing, drug distribution and claims processing.  It necessarily involves the consolidation of patient medication data across all healthcare providers, including:  physicians, hospitals, pharmacies, health plans, pharmacy benefits managers (PBM's), etc., as well as integrating that data with other patient record data in a seamless way.  It goes without saying that whenever the same patient health data is required by more than one provider it should be shared.  Patient medication data is rightfully an integral part of managed care, practice management and the patient record. The consolidation of patient medication data across all healthcare providers and its integration with other patient record data addresses established industry objectives of: patient-focused care, optimal drug therapy, continuity of care and positive patient outcomes.  It benefits everyone involved by assisting the various caregivers in making correct assessments and administering proper medication treatments.  Adopting efficient and effective courses of action, or clinical pathways, for patients with similar diagnosis or procedures is critical to the planning, delivering and measuring of patient care.  The establishment of treatment protocols and standards of care are becoming an important part of healthcare delivery.  Determining proper medication treatments can only be achieved through the analysis of consolidated medication data.  The consolidation and integration of medication data helps managed care providers in evaluating physician activity, prescribing patterns and effectiveness for the establishment of recommended alternative medication treatments.  Being able to compare the costs and outcomes of alternative treatments--pharmacoeconomics--provides the foundation needed to access the value of medication treatment.  Consolidating patient medication data and integrating it with other patient record data is a prerequisite to analyzing outcomes and implementing more effective treatment protocols.  Importantly, this results in better management of healthcare delivery by promoting more efficient utilization of critical healthcare resources and quality of care.  One of the more important uses of consolidated medication data is for outcomes determination.  Emphasis must change from the use of claims and financial data to include medication data.  In addition, outcomes analysis must expand beyond individual clinical encounters to span all aspects of the patient record.  Passive outcomes analysis based on profiles, history and trends may be used to set standards, benchmarks and courses of action, but active outcomes analysis is needed for proper intervention.  Providers must be able to monitor medication therapy and the results in an expeditious, ongoing manner so they can be alerted to possible problems and to determine if the process needs modification.  This presents new requirements for the availability of medication data, which requires the use of a new approach.  Approaches based on "data warehousing," on-line analytical processing (OLAP) or other passive, read-only decision support technologies, do not provide the functionality and structure needed to support dynamic intervention and control.  The linking of medication history data with other patient record data, such as disease progress and laboratory results, can provide insight into patient noncompliance.  The lack of patient compliance is a major problem in the current use of medications.  It often leads to uncontrolled chronic disease, prolonged illness, needless emergency room visits and hospital admissions, all of which contribute to the rising cost of healthcare.  Physicians must be kept informed when prescriptions have not been picked up and when the actual regimen followed varies from that ordered.  As many as 20 percent of all prescriptions written are never(ABSTRACT TRUNCATED)  (Abstract by: Author)

378.    Kegley, J. A. K. (1996). Using genetic information: The individual and the community. Medicine & Law, 15(3), 377-389.
Abstract: Genetic information is both individual and communal (species and family). Responsible use of this information requires exploration of a proper relationship between individual and communal values, rights, needs and decision-making. The individual/community issue is also important for dealing with the differences of emphasis between Western and non-Western cultures in this regard. Non-Western cultures emphasize community but also value the individual, while Western cultures know extreme individualism is counter - productive. This paper will discuss the individual-community relationship as it impacts on various problem areas in the utilization of genetic information, e.g. test results which impact family as well as individuals and which impact institutional projected costs while also making problematic individual access to employment, insurance and health care. The paper will also address the pernicious import of the paradigm of genetic essentialism which exaggerates individual responsibility while neglecting institutional and communal responsibility in genetic matters.  [References: 35]

379.    Kavet, R. (1996). EMF and current cancer concepts. [Review] [197 refs]. Bioelectromagnetics, 17(5), 339-57.
Abstract: Exposure to power frequency electric and magnetic fields (EMF) is ubiquitous, and a body of epidemiologic studies has produced evidence suggestive of a possible link between EMF exposure and cancer of several types. This paper provides a perspective that holds key findings in the EMF literature against the background of important models and established principles in cancer biology. It is intended primarily for scientists whose expertise lies outside of cancer biology and animal bioassays. Current thinking holds that carcinogenesis is a multistep process that requires at least two genotoxic events in its critical path but that is facilitated by nongenotoxic proliferative effects on target cells. EMF, which itself is not believed to be genotoxic, could influence carcinogenesis if it exerted either direct or indirect effects on target cell turnover. Such effects could operate through receptor-mediated or nonreceptor-mediated pathways. However, effects relevant to carcinogenesis have not been confirmed, and a mode of action for EMF has not been determined. Chronic bioassays in rodents are in progress to examine the potential carcinogenicity of EMFs. EMF research has the opportunity to capitalize on the recent major advances in our understanding of carcinogenic processes. [References: 197]

380.    Hurst, K. (1996). The managerial and clinical implications of patient-focused care. Journal of Management in Medicine, 10(3), 59-77.
Abstract: Discusses five elements of patient-focused care (PFC). Clarifies issues surrounding the first element--aggregating patients--and debates the strengths and weaknesses of the second element--centralizing services in PFC units. Explores arguments for and against the third element--multiskilling and cross-training--including staff activity in conventional hospitals and PFC units, in depth. Discusses the structure of PFC teams and their management. Describes the main components of the fourth PFC element--integrated carepaths--and explores their role in clinical audit, computerization and seamless care. Examines the costs of PFC by comparing actual with expected costs. Makes managerial, clinical, educational and research implications throughout for staff working in or with PFC units.  (Abstract by: Author)

381.    Hadlock, C., Niederman, M. S., Stelmach, W. J., Brown, R. B., Tice, A. D., & Bartlett, J. G. (1996). Clinical pathways in an acute care setting: Community-acquired pneumonia. Infectious Diseases in Clinical Practice, 5(SUPPL. 4), S166-S173.

382.    Gros, B. J., Deeb, G. M., & Eagle, K. A. (1996). Aortic dissection: Acute diagnosis and management. Cardiology in Review, 4(2), 112-118.
Abstract: Aortic dissection is a catastrophic illness requiring prompt recognition, diagnosis, and treatment. The cumulative mortality is especially striking in the early hours and days after presentation. This article reviews the clinical presentation of patients with aortic dissection and discusses their acute management. It reviews the modalities currently used in the diagnosis of aortic dissection (magnetic resonance imaging, echocardiography, computed tomography, and aortography). In addition, this article provides a critical pathway to expedite the evaluation and treatment of patients with suspected aortic dissection based on recent studies and our clinical experience.

383.   Griffin, C. C. (1996). Organizational evolution: Critical pathways to substantive change. Journal of Vocational Rehabilitation, 6(1), 69-76.
Abstract: Community-based rehabilitation organizations are undergoing profound change due to the influence of growing consumer self-advocacy, family need, resource redirection and policy change at local, state, and national levels. In changing to best support individuals with disabilities, community-based agencies are restructuring in substantive ways. This paper explores key elements that managers and leaders should consider when instituting change programs in their agencies. The recommendations contained herein are based upon anecdotal information collected while consulting with and providing training to community-based rehabilitation agencies nationwide.

384.    Goode, C. J., Walker, J. B., Ibarra, V., Clancy, G., Hinton, A. T., Mills, R., Hamilton, T., & Reighard, J. (1996). Tracking and analyzing variances from CAREMAPS. K. Kelly (Ed.), Outcomes of effective management practice (Vol. 8pp. 111-121). Thousand Oaks, CA: Sage Publications.

385.    Gill, B. D., & Jenkins, J. R. (1996). Cost-effective evaluation and management of the acute abdomen. Surgical Clinics of North America, 76(1), 71-82.
Abstract: Today, medicine is surging forward onto the information superhighway with increasing focus on capitation, cost containment, critical pathways, and outcome analysis. In applying these principles to surgery, taking an ax to the trunk of the tree entitled 'the acute abdomen' is not a cost-effective step for pruning the individual branches of varied abdominal pathologic conditions. An analysis of the common procedure of appendectomy may allow surgeons to acquire skills that will be necessary in the cost-effective management of patients with all varieties of acute abdominal pathologic conditions.

386.    Frink, B. B., & Strassner, L. (1996). Variance analysis . In D. Flarey Handbook of nursing case management: health care delivery in a world of managed care (pp. 194-223). Gaithersburg, MD: Aspen Publishers.

387.    Elisevich, K., Kasunic, K., Hathaway, S. J., Smith, B. J., Stewart, R. W., & Barkley, G. L. (1996). Clinical care pathways in a surgical epilepsy program: A comparison of costs by diagnostic related groups for program and nonprogram admissions. Journal of Epilepsy, 9(4), 282-290.
Abstract: Specific diagnostic related groups (DRGs) for patients investigated and treated in a surgical epilepsy program have not been established. This has raised concern that admissions into such a program are categorized into DRGs that do not accurately reflect resource consumption. Three DRGs commonly pertain to surgical epilepsy program admissions: 001, 024, and 025. We established clinical care pathways to allow for the diversity of clinical presentations and the differences in subsequent investigation with or without surgical treatment and categorized financial data for 50 patients completing the surgical epilepsy program from June 1993 through December 1994 for the purposes of comparing costs among clinical pathways along with that for 1,401 patients who were not in the program but who were discharged under the same DRGs during the same period. Four clinical pathways contained sufficient patient volume to allow comparison among the pathways and with nonprogram-related admissions under the same DRGs. A considerable range of cost ($1,576-$86,653) was identified among the four most common clinical care pathways. The two pathways involving intracranial electrode implantation followed by prolonged electrographic monitoring were distinguished by the necessity for a subsequent surgical admission as opposed to resection of the epileptogenic area at the time of electrode removal. The cost incurred by an additional admission increased by 14% to $64,305. The mean cost of program patients discharged under each DRG was significantly higher than that for other patients: DRG 001, $28,439 versus $22,289, p < 0.03; DRG 024, $13,479 versus $5,552, p < 0.012; and DRG 025, $9,809 versus $3,033, p < 0.001. The aggregate difference among our 50 patients between total costs incurred for epilepsy surgery cases and the costs that would have been incurred if these patients had the same average costs as patients outside the program was $591,07l. Such findings appear to justify revision of the existing DRG classification to reflect the higher resource consumption by patients with intractable epilepsy.

388.    Edelstein, E. L. (1996). Managing the person with diabetes at home . In S. Blancett (Ed.), Case studies in nursing case management: health care delivery in a world of managed care (pp. 244-257). Aspen Publisher: Gaithersburg, MD.

389.    Chrymko, M. M. (1996). Strategies for implementing pharmaceutical care in a community health system. Hospital Pharmacy, 31(12), 1567-1576.
Abstract: Optimizing pharmaceutical care in an era of cost containment is of paramount importance. Approaches to implementation can differ in each institution. Through staff retreats, short- and long-term goals that complemented our institution's strategic plan were established for the Pharmacy Department. Rather than establishing total pharmaceutical care in a single area and then moving on to other areas, portions of the process were initiated throughout the health system. Creation of clinical pathways and discharge planning provided additional opportunities to work toward optimal pharmaceutical care. Case management in the intensive care unit and anticoagulation management in private physicians' offices were implemented, and cost savings were demonstrated. By identifying opportunities that promote high-quality patient care and support the organization's strategic plan, much progress toward optimized pharmaceutical care has been made.

390.    Belani, K. G. (1996). Anesthesia care and comprehensive quality management. Acta Anaesthesiologica Scandinavica.  Supplementum, 109, 13-15.

391.    Asadi, M. J., & Baltz, W. A. (1996). Activity-based costing for clinical paths. An example to improve clinical cost & efficiency. Journal of the Society for Health Systems, 5(2), 1-7.
Abstract: How much does this medical service or surgical procedure cost the hospital to provide? What is the most efficient clinical pathway that maximizes the quality of patient care while minimizing costs? More and more hospitals are discovering that they don't have solid answers to these critically important questions. In an age of managed care and capitation, however, it is imperative for management to know if the patient care services they provide are making or losing money-and by how much. This article discusses how a powerful new tool called activity-based costing (ABC) can be used to help hospitals accurately determine patient care costs. We show how to build a model that combines both clinical and financial data to measure how efficiently the operation allocates human, material and capital resources to provide its services. The modeling approach described in this article can be used to better analyze a wide range of important operational and financial issues, including: How to efficiently allocate resources, and what resources will be needed as patient demand changes-ideal for operational management and planning; How efficiently activities and processes are performed to meet patient needs-effective for measuring performance and improving quality; Determining clinical pathway profitability-essential for understanding where you're making or losing money; Cycle time, throughput and the impact of resource capacity constraints-critical for meeting patient demand; Costs of idle capacity-important for using resources more efficiently. We will illustrate with an example how this modeling technique can be used to develop and implement efficient clinical pathways

392.    Pearson, S. D., Goulart-Fisher, D., & Lee, T. H. (1995). Critical pathways as a strategy for improving care: problems and potential [see comments]. Annals of Internal Medicine, 123(12), 941-8.
Notes: Comment in: Ann Intern Med 1996 Sep 1;125(5):427-8
Abstract: In an era of increasing competition in medical care, critical pathway guidelines have emerged as one of the most popular new initiatives intended to reduce costs while maintaining or even improving the quality of care. Developed primarily for high-volume hospital diagnoses, critical pathways display goals for patients and provide the corresponding ideal sequence and timing of staff actions for achieving those goals with optimal efficiency. Despite the rapid dissemination of critical pathway programs in hospitals throughout the United States, many uncertainties remain about their development, implementation, and evaluation. In addition, serious concerns have been raised about their effect on patient outcomes and satisfaction with care, physician autonomy, malpractice risks, and the teaching and research missions of many hospitals. Underlying these concerns is the absence of data from controlled trials to evaluate the effects of critical pathways. Physicians should understand the potential benefits and problems associated with critical pathways because physicians are increasingly being asked to provide leadership for pathway programs. Physicians and other health service investigators should also develop methods to study pathways in evolving health care settings. Although the promise of reduced costs and improved quality is enticing, the gaps in our knowledge about critical pathways are extensive; therefore, like any new health care technology, pathway programs should be fully evaluated in order to understand the conditions under which that promise may be fulfilled

393.    Morris, E., & Mylotte, A. (1995). The management of childhood asthma through care pathways. Nursing Times, 91(49), 36-7.
Abstract: The incidence of childhood asthma is on the increase with mounting pressure on health professionals caring for these children. Any attempt to develop services for children with asthma must address the problem of coordinating care between hospitals, GPs and community nurses, and should include the issue of parental involvement. This paper describes how a care pathway is used as a tool to promote partnerships of care between hospital, community and the family, and to coordinate the service.  (4 ref)

394.    Yandell, B. (1995). Critical paths at Alliant Health System. Quality Management in Health Care, 3(2), 55-64.
Abstract: Alliant Health System (Alliant) was an enthusiastic, early user of critical paths in a hospital setting. In spite of its apparent early successes with the approach, Alliant eventually dropped critical paths as an overall corporate strategy and redesigned its approach to those critical paths still in use. This article summarizes the lessons learned and offers suggestions on the use of critical paths.  (Abstract by: Author)

395.    Turley, K. M., Higgins, S. S., Archer-Duste, H., & Cafferty, P. (1995). Role of the clinical nurse coordinator in successful implementation of critical pathways in pediatric cardiovascular surgery patients. Progress in Cardiovascular Nursing, 10(1), 22-6.
Abstract: Critical pathways reduce variations in clinical management and achieve quality patient outcomes within a defined time while reducing the average length of stay (ALOS). The critical path is a day-by-day plan that specifies the use and timing of procedures in relation to the stage in the patient's recovery. Variations from that plan are identified and aggressively approached. This article outlines the clinical nurse coordinator's role in utilizing critical pathways for the congenital heart surgery patients. Successful implementation of the pathways using the clinical nurse coordinator's role is supported by analysis of ALOS in 286 patients.  (17 ref)

396.    Schriefer, J. (1995). Managing critical pathway variances. Quality Management in Health Care, 3(2), 30-42.
Abstract: As the use of critical pathways expands at an increasing rate, we are faced with the issue of how to manage variances from the pathway. Variance management is not clearly defined in the literature, and many institutions search for the best approach. We have implemented a number of different techniques for variance management at Fletcher Allen Health Care. Our success benefits both patients and providers.  (Abstract by: Author)

397.    Remmlinger, E., Ault, S., & Hanrahan, L. (1995). Information technology implications of case management. Healthcare Information Management, 9(1), 21-8.
Abstract: Information technology is a critical component to implementing a comprehensive and effective case management process. The vendor marketplace is aggressively working to address gaps in function and integration. In the meantime, organizations must begin now to plan their case management processes. This is no small task. Most organizations are struggling to develop the necessary manual systems through consensus building on a multidisciplinary basis. Success in developing and implementing a good manual system, although cumbersome, is an essential prerequisite to automation. Major organizational growth and restructuring is already under way in most settings to respond to the pressures of health care reform. Availability of a tight case management process with appropriate information technology support is the key to success.  (Abstract by: Author)

398.    Nolin, C. E. (1995). Malpractice claims, patient communication, and critical paths: a lawyer's perspective. Quality Management in Health Care, 3(2), 65-70.
Abstract: Patient confusion and anger resulting from poor provider-patient communication are major factors giving rise to malpractice claims. This article uses the true story of Patient X to explore how communication issues contribute to claims. It also studies the motives of malpractice plaintiffs within the context of the scholarly literature. The article concludes that critical paths can play a positive role in ensuring timeliness, consistency, thoroughness, and patient comprehension of key communication. If used correctly, critical paths can address some of the root causes of malpractice suits.  (Abstract by: Author)

399.    Luttman, R. J., Laffel, G. L., & Pearson, S. D. (1995). Using PERT/CPM (Program Evaluation and Review Technique/Critical Path Method) to design and improve clinical processes. Quality Management in Health Care, 3(2), 1-13.
Abstract: Recent changes in health care have focused attention on new tools for planning and managing clinical processes. The use of one tool in particular, clinical pathways, has increased dramatically. Pathways employ a concept long used in other industries: the explicit design and documentation of a process. However, the most common tools used in other industries to perform process design, the Program Evaluation and Review Technique (PERT) and the Critical Path Method (CPM), have not migrated to health care. This article presents a methodology for incorporating PERT/CPM into the design and management of clinical processes.  (Abstract by: Author)

400.    Korycan, T. (1995). Achieving cost and quality benefits in critical pathway implementation. Quality Management in Health Care, 3(2), 71-3.

401.    Koch, M. O. (1995). Orthotopic neobladder reconstruction after radical cystectomy. Techniques in Urology, 1(4), 197-203.
Abstract: Urinary diversion with continent urinary reservoirs to the urethra offer major advantages to patients with invasive bladder carcinoma. Multiple configurations for pouch creation have been described, however, there are unifying concepts between all types of continent diversions which should be adhered to in order to optimize outcome. These general concepts are discussed and the author's technique for small and large intestinal neobladder construction is presented. Perioperative management is delivered using a collaborative care critical pathway technique and has resulted in excellent outcomes

402.    Farley, K. (1995). The COPD critical pathway: a case study in progress. Quality Management in Health Care, 3 (2), 43-54.
Abstract: Patients with chronic obstructive pulmonary disease (COPD) consume many health care resources and require complex coordination of care among multiple caregivers. In this report, we share our experiences at Fletcher Allen Health Care, Burlington, Vermont, in developing and implementing a critical pathway for these patients. The COPD pathway has resulted in measurable improvements in the quality of care and has provided us with lessons that will enhance our use of critical pathway methods.  (Abstract by: Author)

403.    Coffey, R. J., Othman, J. E., & Walters, J. I. (1995). Extending the application of critical path methods. Quality Management in Health Care, 3(2), 14-29.
Abstract: Most health care organizations are using critical pathways in an attempt to reduce the variation in patient care, improve quality, enhance communication, and reduce costs. Virtually all of the critical path efforts to date have developed tables of treatments, medications, and so forth by day and have displayed them in a format known as a Gantt chart. This article presents a methodology for identifying the true "time-limiting" critical path, describes three additional methods for presenting the information--the network, precedent, and resource formats--and shows how these can significantly enhance current critical path efforts.  (Abstract by: Author)

404.    Keeney, S. M. (1995-1996). Pediatric case management. The critical path. Rehab Management: The Interdisciplinary Journal of Rehabilitation, 8(1), 55-56,58.
Abstract: Mapping out the services a child will need upon returning to home and school

405.    Wood, H. A. (1995). A collaborative practice model in a community hospital. Nursing Management, 26(12), 57-9.

406.    Wieczorek, P. (1995). Developing critical pathways for the operating room. AORN Journal, 62(6), 925-9.
Abstract: Case management and managed care systems are emerging in the 1990s as ways to deliver quality, cost effective patient cae. The essential tool of managed care systems is a critical pathway, which is developed through the collaboration of health care team members. The critical pathway is an abbreviated version of the patients hospital course according to his or her medical diagnosis or case type and it allows health care team members to continually evaluate the patients care. It has helped team members at Johns Hopkins Hospital, Baltimore, identify more effective and cost-efficient ways to deliver patient care

407.    Terhaar, M., & O'Keefe, S. (1995). A new advanced practice role focused on outcomes management in women's and children's health. [Review] [24 refs]. Journal of Perinatal & Neonatal Nursing, 9(3), 10-21.
Abstract: Outcomes management involves goal-directed coordination of transdisciplinary teams. It focuses on achieving measurable outcomes for select populations of patients. The article presents a new advanced practice role focused on outcomes management for the perinatal population. Practice pattern reforms accomplished during 3 years of work and the associated favorable clinical, functional, service, quality, and financial outcomes are described. Supports required for the success of an outcomes management program as well as lessons learned from 2 years work are presented. [References: 24]

408.    Tallon, R. (1995). Devising and delivering objectives for disease state management. Nursing Management, 26(12), 22-4.
Abstract: Comprehensive, objective plans of clinical care that reflect the optimal diagnosis and treatment must be developed. Standardized plans of patient care that are centered around a specific disease entity meet outcomes management and maximize health delivery quality. This integration is embodied in the philosophy of disease state management

409.    Stack, L., & Jezierski, M. (1995). ED staff seeks critical pathways with non-computer-assisted multidisciplinary documentation tool. Journal of Emergency Nursing, 21(6), 486.

410.    Spath, P. L. (1995). Paths remind caregivers of record requirements. Hospital Case Management, 3(12), 192-195.

411.    Sarkissian, S., & Wallace, C. (1995). Clinical indicators contributing to I.C.U. length of stay in elective craniotomy patients with brain tumour. Axone, 17(2), 42-5.
Abstract: The immediate purposes of this study are (a) to indicate the I.C.U. and hospital length of stay in elective craniotomy patients with brain tumour, and (b) to identify the clinical indicators that contribute to the I.C.U. length of stay. The ultimate purpose is to contribute to a growing body of knowledge in providing quality and cost effective patient outcomes by creating appropriate vehicles for further research in the field of neuroscience. The following clinical indicators are identified: pre-op patient admission to ward or same day admit unit, O.R. cancellations, type of tumour, nursing staff availability, intubation on admission, I.C.U. length of stay, and post-op complications. The results of this pilot study, with sample size of 55 patients, could assist us in the nursing profession to develop an appropriate Care Map for craniotomy patients with brain tumour

412.    Pellegrin, K. L., Carek, D., & Edwards, J. (1995). Use of experimental and quasi-experimental methods for data-based decisions in QI. Joint Commission Journal on Quality Improvement, 21(12), 683-91.
Abstract: BACKGROUND: Decisions made by quality improvement (QI) teams, as reported in the literature, are usually based on nonexperimental methods for data collection. Pretest-posttest designs, in particular; are common in reports of QI teams' evaluations of changes or interventions. Yet in such designs the results are inherently confounded; it is impossible to rule out alternative explanations for any differences found. USING EXPERIMENTAL METHODS TO MAKE QI DECISIONS: As suggested by one study, QI teams can design and implement experimental interventions in relevant organizational processes. In an attempt to reduce the no-show rate for first appointments at a Residents Clinic at the Medical University of South Carolina (Charleston), the Youth Outpatient Improvement Team designed an experiment to test two possible modifications to the admission process. Those seeking services were randomly assigned to one of three groups (the control group or one of the experimental groups). Not only did results not support the team's hypothesis that one of the experimental procedures would produce a lower no-show rate, subjects in the experimental groups were less likely to enter treatment. Given these data, the decision was made to maintain current admission procedures. CONCLUSIONS: Since the quality of a decision is dependent on the quality of the data on which it is based, QI teams should consider experimental methods when planning data collection to evaluate their recommended interventions. When such methods are not feasible, quasi-experimental strategies can be used to strengthen the quality of nonexperimental data

413.    Painter, L. M., Dudjak, L. A., Breiner, K., & Langford, A. (1995). Abdominal aortic aneurysm pathway: outcome analysis.  Journal of Vascular Nursing, 13(4), 101-5.
Abstract: The current and future health care environment demands that health care providers place increased emphasis on the achievement of acceptable patient outcomes within an effective timeline and with more efficient use of resources. Clinical pathways provide a tool that defines the processes and activities that must occur to meet these goals. The purpose of this study is to describe a process for analysis of clinical and fiscal outcomes of a clinical pathway initiated at an academic medical center for elective abdominal aortic aneurysm repair. Patients were monitored throughout their preoperative and postoperative course to identify and trend variances, assess opportunities for improved resource use, and determine patient/family satisfaction. Data were collected by use of multiple electronic databases available within the university information systems network and analyzed to determine impact on patient charges, treatment course, and length of stay. Outliers were profiled as a means to identify prognostic indicators or establish a high preoperative risk. Results of a sample of 42 patients revealed a reduction in gross charges by 33% per case in comparison to the baseline data obtained before pathway implementation. This study will describe the rationale and process for instituting changes in resource use, such as diagnostic testing and blood use. Clinical outcomes and related nursing implications will also be discussed, including preoperative management, a streamlined same-day admission process, and factors associated with prolonged stay in the intensive care unit. Finally, strategies designed to enlist the support and participation of nurses, physicians, and other health team members will be discussed

414.    Odderson, I. R., Keaton, J. C., & McKenna, B. S. (1995). Swallow management in patients on an acute stroke pathway: quality is cost effective. Archives of Physical Medicine & Rehabilitation, 76(12), 1130-3.
Abstract: OBJECTIVE: To assess the effects of swallowing management in patients with acute nonhemorrhagic stroke placed on a clinical pathway, and to evaluate whether swallow function on admission can be used as a predictor of length of stay (LOS) and outcome disposition. DESIGN: Intervention study to reduce complications of dysphagia in patients with acute stroke. SETTING: Urban community hospital. PATIENTS: Data were collected on 124 patients with acute nonhemorrhagic stroke admitted from January to December 1993. INTERVENTIONS: A swallow screen was completed within one day of admission and before any oral intake. MAIN OUTCOME MEASURES: Dysphagia and functional independence measure (FIM) scores on admission, occurrence of aspiration pneumonia, LOS, outcome disposition and cost effectiveness analysis. RESULTS: Thirty-nine percent of all patients (p < .05) failed the initial swallow screen and required altered dietary texture and intervention. No patients developed aspiration pneumonia. Of those with dysphagia, 21% recovered intact swallowing by discharge; 19% required gastrostomy tube placement. Patients with dysphagia had lower admission FIM scores than nondysphagia patients. The LOS was longer for the dysphagia group (8.4 +/- 0.9 days) compared with patients without dysphagia (6.4 +/- 0.6 days, p < .05). Patients with dysphagia were less likely to be discharged to home (27%) than were nondysphagia patients (55%), and twice as likely to be discharged to a nursing home (p < .05). CONCLUSIONS: This study demonstrates that early swallow screening and dysphagia management in patients with acute stroke reduces the risk of aspiration pneumonia, is cost effective, and assures quality care with optimal outcome

415.    Lee, F. C. (1995). Disease management in the treatment of cancer. Medical Interface, 8(12), 126-31.

416.    Kidd, P., & Sturt, P. (1995). Developing and evaluating an emergency nursing orientation pathway. Journal of Emergency Nursing, 21(6), 521-30.
Abstract: Objective Orientee evaluation forms frequently focus on tasks and technical skills rather than decision-making skills. An orientation pathway was developed to evaluate orientee clinical decision-making skills. The pathway can assist in identifying orientees who require additional educational resources or interventions. Early interventions may decrease the length of orientation, increase an employee's length of stay in the institution, and contribute to cost savings. Methods The pathway was developed with employee exit interview data, preceptor interviews, identification of critical indicators, and the orientation literature. The pathway consists of six categories. Indicators within each category were identified and ranked according to four levels of proficiency (level 1 for the least proficient and level 4 for the most proficient). A convenience sample of seven ED orientee and preceptor pairs agreed to participate in the pilot use of the pathway. An expected timeline of progress had been developed by a group of 20 preceptors during a preceptor workshop. An average proficiency level (score) was obtained for each category for 12 weeks with the weekly scores plotted on the pathway. This level was compared with the expected proficiency level in each category for each week. Demographic information was obtained from the orientee and preceptor pairs to determine whether certain characteristics facilitate pathway progression. Data were analyzed with frequency distributions, and measures of central tendency and variance. Spearman's rank correlations were used to examine the proficiency level in each category for each week in relation to demographic characteristics of the preceptor and orientee. Results Orientees progressed faster than expected in all categories. It took 8 weeks for an orientee to attain the highest proficiency level in all categories. The fastest progress was made in the category "Accurately Evaluates Patient Responses." Slowest progress was made in the category "Safety in Blood and Drug Administration." Preceptors and orientees rated the pathway as very useful. Discussion Further studies with the orientation pathway may help to determine the ideal time frame for orientation, characteristics of orientees who progress as expected or faster, and educational strategies to facilitate orientee progression and clinical decision making.  (5 ref)

417.    Graybeal, K., & Peterson, R. (1995). CRITICAL PATH NETWORK. Pathway promotes smooth hospital-SNF transitions. Hospital Case Management, 3(12), 187-190.

418.    Dubbs, W. H. (1995). Tools for managing the demand for services. AARC Times, 19(12), 32-4.

419.    Del Togno-Armanasco, V., & Gwozdz, D. T. (1995). Notes from the field. Let's trash the care plan! Nursing Management, 26(12), 54.

420.    Coltey, R. W. (1995). Materiel managers: survival under managed care. Journal of Healthcare Resource Management, 13(12), 8-11-4.
Abstract: Managed care by healthcare providers is becoming the method of choice for controlling costs. Insurance companies, employers, employees as well as healthcare providers are all doing what they can to understand and practice economical managed care. With financial systems that reimburse healthcare providers now moving to a capitated approach, providers need to get away from a cost-plus mentality. More than ever materiel managers need to realize that providers are moving from revenue to expense accounting. Under capitation many, if not all, of management philosophy must change to compete in the new healthcare delivery environment.  (Abstract by: Author)

421.    Calligaro, K. D., Dougherty, M. J., Raviola, C. A., Musser, D. J., & DeLaurentis, D. A. (1995). Impact of clinical pathways on hospital costs and early outcome after major vascular surgery. Journal of Vascular Surgery, 22(6), 649-57; discussion 657-60.
Abstract: PURPOSE: The purpose of this study was to determine whether major vascular surgery could be performed safely and with significant hospital cost savings by decreasing length of stay and implementation of vascular clinical pathways. METHODS: Morbidity, mortality, readmission rates, same-day admissions, length of stay, and hospital costs were compared between patients who were electively admitted between September 1, 1992, and August 30, 1993 (group 1), and January 1 to December 31, 1994 (group 2), for extracranial, infrarenal abdominal aortic, and lower extremity arterial surgery. For group 2 patients, vascular critical pathways were instituted, a dedicated vascular ward was established, and outpatient preoperative arteriography and anesthesiology-cardiology evaluations were performed. Length-of-stay goals were 1 day for extracranial, 5 days for aortic, and 2 to 5 days for lower extremity surgery. Emergency admissions, inpatients referred for vascular surgery, patients transferred from other hospitals, and patients who required prolonged preoperative treatment were excluded. RESULTS: With this strategy same-day admissions were significantly increased (80% [145/177] vs 6.2% [9/145]) (p < 0.0001), and average length of stay was significantly decreased (3.8 vs 8.8 days) (p < 0.0001) in group 2 versus group 1, respectively. There were no significant differences between group 1 and group 2 in terms of overall mortality rate (2.1% [3/145] vs 2.3% [4/177]), cardiac (3.4% [5/145] vs 4.0% [7/177]), pulmonary (4.1% [6/145] vs 1.7% [3/177]), or neurologic (1.4% [2/145] vs 0% [0/177]) complications, or readmission within 30 days (11.3% [16/142] vs 9.2% [16/173]) (p > 0.05). There were also no differences in morbidity or mortality rates when each type of surgery was compared. Annual hospital cost savings totalled $1,267,445. CONCLUSION: Same-day admission and early hospital discharge for patients undergoing elective major vascular surgery can result in significant hospital cost savings without apparent increase in morbidity or mortality rates

422.    Turley, K., Tyndall, M., Turley, K., Woo, D., & Mohr, T. (1995). Radical outcome method. A new approach to critical pathways in congenital heart disease. Circulation, 92(9 Suppl), II245-9.
Abstract: BACKGROUND: Treatment of congenital heart disease has entered a new era of healthcare delivery and cost containment. Critical pathway method (CPM) has been previously demonstrated by us to produce a significant reduction in average length of stay (ALOS) in hospital of -44%. A new approach, radical outcome method (ROM), has produced comparable results that appear to improve over time. The dynamic nature is examined. METHODS AND RESULTS: Two hundred consecutive patients with congenital heart disease were treated by a single surgeon at a single health maintenance organization (HMO) facility. ROM was used in all patients. This method uses seven critical moments at which shortening rather than confirmation of the ALOS is possible. This process is completed by the second post-operative day. Overall mortality was 1%. The 200 patients were divided into two consecutive groups of 100 patients to determine the effectiveness of ROM over time. Fifty sets were matched. ALOS hospital decreased by 29 days (mean, 0.6 d/set), P < .003. Thirty sets who underwent cardiopulmonary bypass had a 16% decrease (P < .03), and 20 sets in whom nonbypass procedures were performed had a decrease of 16% (P < .02). ALOS in hospital for the 50 sets decreased from 3.7 to 3.1 days (-16%, P < .003). Outcome data demonstrated no significant difference. CONCLUSIONS: ROM, a proactive approach to hospital stay, is a dynamic process that reduces ALOS in hospital. This is achieved by both reducing negative variation in the standard CPM and allowing for positive variation. Outcome data confirm that this approach can reduce ALOS in hospital while providing optimal patient care and family satisfaction, a standard for the new era of healthcare delivery

423.    Sprouse, M. W., & Whitmore, B. C. (1995). Developing a hospital policy for clinical pathways. Journal for Healthcare Quality, 17(6), 40-51.
Abstract: Clinical pathways are used for planning, coordinating and facilitating the continuum of patient care from before admission to after discharge. They rapidly are changing the provision of healthcare services through improved patient care and cost containment, but they also have raised questions about possible legal ramifications. If sound policies and procedures for clinical pathways are developed and consistently adhered to by healthcare facilities, the potential for liability may be minimized while patient care is improved. This article describes a multidisciplinary task force's work to develop such policies and procedures.  (Abstract by: Author)

424.    Spath, P. L. (1995). Path-based patient care should build quality into the process. Journal for Healthcare Quality, 17(6), 26-9.
Abstract: Clinical paths can help caregivers "do the right thing the first time" for the individual patient. They also can help to continually improve the system of providing care for future patients. By comparing what should be happening (according to the clinical path) with what actually is happening, the healthcare team can design an effective plan for patient care. By gathering data about the patient care experience, the healthcare team can redesign care for future patients. This article describes important concurrent and retrospective activities of path-based patient care and the ways in which healthcare providers are using clinical paths to improve patient outcomes.  (Abstract by: Author)

425.    Rossiter, D., & Thompson, A. J. (1995). Introduction of integrated care pathways for patients with multiple sclerosis in an inpatient neurorehabilitation setting. Disability & Rehabilitation, 17(8), 443-8.
Abstract: Rehabilitation of progressive neurological disorders such as multiple sclerosis poses particular problems, and clear setting of goals and clinical audit are essential for effective management. Integrated care pathways (ICPs) offer a unique opportunity to document and audit the rehabilitation process. This preliminary study has shown that ICPs are useful in both assessing process and auditing goals. Their introduction has led to the identification of the key worker role within the neurorehabilitation unit (NRU), and has provided an opportunity to increase the participation of patients and carers in the rehabilitation process. Continuing refinement of the pathway is necessary, and its application to other neurological disorders such as cerebrovascular accident may be appropriate

426.    McCormick, K. (1995). Integrating today's computers, outcomes, and quality for tomorrow's health care. Informatics in Healthcare Australia, 4(5), 183-7.
Abstract: Growing attention to outcomes of care, effectiveness, efficiencies, clinical practice guidelines and costs is changing health systems globally. Developments in decision support systems, quality assurance systems, effectiveness systems, costs containment systems, and networks are required to integrate administrative data and patient care for determining outcomes and resource management. Network based systems using Internet have the potential not only to link us globally, but also to link us to science-based knowledge in making clinical decisions at the point of care. This paper describes new tools required to integrate outcomes data, clinical practice guidelines, and content in the computer-based patient record. In addition, the paper defines review criteria related to clinical practice guidelines which produce clinical paths, and performance measures which provide benchmarks of comparison among provider of care sites. The impact on cost and quality that is emerging will also be described.  (27 ref)

427.    McCamish, M. A. (1995). Critical pathways for improved outcome using nutrition support [editorial]. Nutrition, 11(6), 766-7.

428.    Janken, J. K. (1995). Cabinet on research. Critical pathways: what they are and what they are not... what critical pathways are not. Tar Heel Nurse, 57(6), 36-7.

429.    Huff, M. (1995). Critical paths for critical functions? An evolving discharge planning pathway. Continuum (Chicago), 15(6), 1-3-8.

430.    Havighurst, C. (1995). The power circuit. Strategically integrated information systems could rescue hospitals from :servant: status. Health Systems Review, 28(6), 21-4-52.

431.    Grant, P. H., Campbell, L. L., & Gautney, L. J. (1995). Implementing case management and developing clinical pathways. Journal for Healthcare Quality, 17(6), 10-6.
Abstract: Efforts to implement case management and, subsequently, to develop critical paths at Birmingham Baptist Medical Center Montclair in Birmingham, AL, began in the late 1980s. Under the case management system, registered nurses using the CareMap system manage the care of 60-80% of the medical center's patients. Those patients whose care does not follow a map are managed by nurse case managers. The patients who do not meet the identified goals for care require a collaborative effort from all the healthcare professionals associated with their care. Since the inception of the case management program, Montclair has made significant strides in decreasing the cost per discharge, decreasing the variable cost per case, and, most importantly, improving quality outcomes for designated case types.  (Abstract by: Author)

432.    Goode, C. J. (1995). Impact of a CareMap and case management on patient satisfaction and staff satisfaction, collaboration, and autonomy. Nursing Economics, 13(6), 337-48, 361.
Abstract: The purpose of this research was to evaluate the effect of a CareMap and nursing case management on patient satisfaction and staff job satisfaction, collaboration, and autonomy. The patients who had a CareMap and a nurse case manager were more satisfied with their care. The multidisciplinary staff who worked on the experimental unit had increased job satisfaction and nurses who applied and were selected for case management positions had higher levels of collaboration and increased autonomy. Multidisciplinary team members who developed the CareMap also had higher levels of collaboration than other multidisciplinary staff on the experimental unit and their job satisfaction with quality of care increased under this new care delivery system

433.    Garbin, B. A. (1995). Introduction to clinical pathways. Journal for Healthcare Quality, 17(6), 6-9; quiz 9-29.
Abstract: A clinical pathway is a comprehensive method of planning, delivering, and monitoring patient care. As efforts continue to streamline the delivery of services at all levels of care and settings, it is essential that quality management and utilization management professionals respond in a proactive manner to facilitate quality outcomes while decreasing cost and increasing efficiency. The use of clinical pathways, as one part of a facility's or an organization's total quality management program, may be the answer to this challenge.  (Abstract by: Author)

434.    Bliss-Holtz, J. (1995). Computerized support for case management ISAACC... the Professional Care System Intelligent System Access to Automated Clinical Charting. Computers in Nursing, 13(6), 289-94.
Abstract: As the discipline of nursing strives to remain the logical orchestrator of case management, the ideal tool to support this effort would be based on a practice-oriented nursing theory. One such theory, Self-Care Deficit Nursing Theory, has formed a base for a computerized system that has the potential to support case management. This article briefly describes the Professional Care System and the component of the system that can support case management: Intelligent System Access to Automated Clinical Charting (ISAACC) and plans for further expansion of the system.  (20 ref)

435.    Bernstein, L. H., & Bissell, M. G. (1995). Clinical pathways: Part 2. Clinical Laboratory Management Review, 9(6), 503-5.

436.    Balesky, J. R., & Provenzano, L. M. (1995). Collaborative development of a clinical pathway for congestive heart failure. Journal for Healthcare Quality, 17(6), 30-5-38-9.
Abstract: Bon Secours Hospital, a 304-bed community hospital in Grosse Pointe, MI, decided to target high-volume and high-cost DRGs for clinical process improvement. Working collaboratively with members of the medical staff, the cardiac team set out to improve outcomes by reducing the non-value-added costs and the variations in the treatment of patients with congestive heart failure (CHF). A comprehensive program of care for these patients, that included the full continuum of care, from prevention to maintenance, is being developed, using a clinical pathway to manage the acute phase of treatment.  (Abstract by: Author)

437.    Ayestas, A. L., Diaz, E., & Kirtland, S. (1995). Clinical pathways: improving patient education and influencing readmission rates. Journal for Healthcare Quality, 17(6), 17-25; quiz 29-47.
Abstract: Clinical pathways have long been used as a mechanism for implementing a managed care delivery system. They have been effective in highlighting lengths of stay, outcome variances, and systems problems. Clinical pathways play an important part in enhancing quality improvement activities, especially in accordance with the standards of the Joint Commission on Accreditation of Healthcare Organizations. This article addresses benefits of clinical pathways in general, and benefits at the authors' facility in particular, specifically, a clinical pathway's effectiveness in influencing readmissions of patients with atrial fibrillation.  (Abstract by: Author)

438.    Zablocki, E. (1995). Using disease state management to coordinate care across the continuum. Quality Letter for Healthcare Leaders, 7(9), 2-10.

439.    Yetter, D. (1995). Critical pathways in the emergency department. Nursing Management, 26(11), 60.

440.    Shattuck, D. (1995). The name of the game is change: Fred Hutchinson Cancer Research Center's clinical nutrition department is ahead of the game. Journal of the American Dietetic Association, 95(11), 1255-6.

441.    McCormick, K. A. (1995). Including oncology outcomes of care in the computer-based patient record. [Review] [44 refs]. Oncology, 9(11 Suppl), 161-7.
Abstract: Changes in the health care system have caused a shift in research to outcomes of care, effectiveness, efficiencies, clinical practice guidelines, and costs. The greater use of computer systems, including decision support systems, quality assurance systems, effectiveness systems, cost containment systems, and networks, will be required to integrate administrative and patient care data for use in determining outcomes and resource management. This article describes developments to look forward to in the decade ahead, including the integration of outcomes data and clinical practice guidelines as content into computer-based patient records; the development of review criteria from clinical practice guidelines to be used in translating guidelines into critical paths; and feedback systems to monitor performance measures and benchmarks of care, and ultimately cost out cancer care. [References: 44]

442.    Mayne, J. E. (1995). Teaching path balances LOS, education needs for MI. Hospital Case Management, 3(11), 171-4.

443.    Lee, T. H. (1995). Collaborating to reduce costs in invasive cardiology: the Partners Healthcare experience. Partners Healthcare Invasive Cardiology Team. Joint Commission Journal on Quality Improvement, 21(11), 593-9.
Abstract: BACKGROUND: As part of the closely watched marriage between Brigham and Women's Hospital and Massachusetts General Hospital, the invasive cardiology team--cardiologists and other staff from the two organizations--began with monthly meetings; its mission is to reduce costs of cardiology services while maintaining or improving patient satisfaction and outcomes. IMPROVEMENT EFFORTS: Joint purchasing efforts have led to substantial price reductions for some supplies, such as pacemakers and balloon angioplasty. However, concern over quality drove cardiologists to choose newer, more expensive models of other supplies, such as implantible cardioverter-defibrillators. Also, the team is studying the actual costs savings that can be achieved by shifting patients undergoing cardiac catheterization to the outpatient setting. In addition, cardiologists recognized an opportunity to decrease length of stay and increase quality by removing the arterial sheath for uncomplicated percutaneous transluminal coronary angioplasty patients on the same day the procedure is performed. Each hospital is developing strategies for this change in procedure. In addition to these improvement efforts, the team is encouraging optimal use of contrast agents and increasing overall efficiency of laboratories. Team members are also sharing guidelines and critical pathways and developing strategies for evaluating new technologies. LESSONS LEARNED: The team has had little difficulty in achieving a collegial atmosphere and consensus around clinical issues and products once clinicians are face-to-face. Announcing bimonthly meetings may overcome meeting scheduling difficulties. The other major stumbling block has been the lack of detailed cost information

444.    Jeon, A. A. (1995). A hospital administrator's view of the operating room. Journal of Clinical Anesthesia, 7 (7), 585-8.
Abstract: The need for greater efficiency in OR management will become apparent as hospitals are forced to respond to a myriad of pressures imposed by the external environment. The most effective strategy in dealing with this challenge will be realized by adopting a "systems" approach to OR functions as opposed to the more traditional methodology that emphasizes a review of individual problematic components. One issue that challenges many ORs is "throughput": the backlog of patients in ORs that occurs because the recovery room is filled to capacity. The traditional approach is to focus on the recovery room's inefficiency and to expend energy on improving recovery room function. A "systems" approach would examine all factors that affect recovery room function and analyze the interdependencies that exist between the recovery room and other hospital service functions. These might include the way cases in the OR are scheduled, as well as issues that involve patient transfer from the recovery room to intensive, intermediate, and routine floor care. By establishing a dialogue with parties outside of the traditional OR community, the opportunity to solve problems that affect the OR but that are outside of its direct sphere of control, presents itself. This approach will require the acquisition of new skills by those responsible for OR management in addition to promulgating a change in the culture that dominates many ORs today. An insular approach that reinforces the concept of the OR as a microcosm unto itself is an outmoded one. The hospital community at large will benefit from the expert skills possessed by those proficient in efficient OR management, while enabling the OR to fulfill its mission in the challenging times ahead

445.    Hurt, L. W. (1995). Care management: providing a connecting link. Nursing Management, 26(11), 27-30, 32-33.
Abstract: Care management monitors the variances of the entire patient population in a given area versus specific cases as demonstrated in case management. It includes CQI principles, variance analysis and regulatory standards. Care management serves as a conduit for continuing education, involves a multidisciplinary team approach, which involves the family and assists managed care and utilization review

446.    Grover, F. L., Hammermeister, K. E., & Shroyer, A. L. (1995). Quality initiatives and the power of the database: what they are and how they run. [Review] [15 refs]. Annals of Thoracic Surgery, 60(5), 1514-21.
Abstract: The criteria by which healthcare is judged or measured are quality, accessibility, and cost effectiveness. To evaluate these criteria it is important to have a database. There are many strengths and weakness to large databases. They can be used as an indicator of the level of performance or quality, for clinical decision making, and as a measurement of cost effectiveness. They can also be useful in the evaluation and development of treatment algorithms and critical pathways for patients with entry level disease. In addition, they can measure patient access to healthcare and the appropriateness of care. It is important for these databases to appropriately adjust for preoperative risk factors that may influence outcome. Outcome in most of the databases is measured by mortality, but morbidity, functional status, quality of life, cost of care, length of stay, return to work, and patient satisfaction are also important outcomes. Factors that can influence the quality of the outcome data are the methods by which the data are collected, standardization of definitions, the currentness of the database, adequate numbers of patients and outcomes, and appropriate analytic techniques. It is important to feed back the data to the healthcare providers in a timely enough fashion so that processes and structures of care can be modified to improve treatment and results. The reliability of the databases and the validity must be substantiated for the healthcare provider to have confidence in the database.(ABSTRACT TRUNCATED AT 250 WORDS) [References: 15]

447.    Ely, B. A., Walker, R., & Berger, T. (1995). Case management in a small rural hospital. Nursing Management, 26(11), 64-6.

448.    Ecklund, M. M. (1995). Optimizing the flow of care for prevention and treatment of deep vein thrombosis and pulmonary embolism. [Review] [23 refs]. AACN Clinical Issues, 6(4), 588-601; quiz 680-2.
Abstract: Critically ill patients have multiple risk factors for deep vein thrombosis and pulmonary embolism. The majority of patients with pulmonary embolism have a lower extremity deep vein thrombosis as a source of origin. Pulmonary embolism causes a high mortality rate in the hemodynamically compromised individual. Awareness of risk factors relative to the development of deep vein thrombosis and pulmonary embolism is important for the critical care nurse. Understanding the pathophysiology can help guide prophylaxis and treatment plans. The therapies, from invasive to mechanical, all carry risks and benefits, and are weighed for each patient. The advanced practice nurse, whether in the direct or indirect role, has an opportunity to impact the care of the high risk patient. Options range from teaching the nurse who is new to critical care, to teaching patients and families. Development of multidisciplinary protocols and clinical pathways are ways to impact the standard of care. Improved delivery of care methods can optimize the care rendered in an ever changing field of critical care. [References: 23]

449.    Di Giulio, N. (1995). Introduction to critical pathways: what every RCP should know. AARC Times, 19(11), 24-9.

450.    Bunch, D. (1995). Hitting the road to success with care maps. AARC Times, 19(11), 20-23.

451.    Blegen, M. A., Reiter, R. C., Goode, C. J., & Murphy, R. R. (1995). Outcomes of hospital-based managed care: a multivariate analysis of cost and quality. Obstetrics & Gynecology, 86(5), 809-14.
Abstract: OBJECTIVE: To determine the effects a hospital-based managed care intervention has on the cost and quality of care. METHODS: The intervention consisted of a CareMap and a nurse case manager. The CareMap contained both a critical path and a set of expected patient outcomes. The study population comprised all women who delivered by cesarean during the 18 months of the study and who were cared for in the maternity unit at a tertiary-level university hospital. The effects of the intervention were determined by comparing the after group with the before group in regard to length of stay and costs of care post-cesarean delivery, patient ratings of quality of care, and the physical recovery of the patients by discharge and 1 month later. RESULTS: After the implementation of hospital-based managed care, the average length of stay decreased 13.5% (0.7 days) and the average costs decreased 13.1% ($518). These decreases were statistically significant and remained so after controlling for co-morbid and complicating conditions. Patients perception of the quality of care increased from 4.26 to 4.41 on a 1-5 scale, a statistically significant increase. In particular, patients believed that they had an increased level of participation in their care. The physical recovery scores obtained at discharge did not change. CONCLUSION: Hospital-based managed care can reduce resource use, length of stay, and cost associated with hospital care while maintaining or improving the quality of care. Whether these effects are reproducible and generalizable to other conditions should be addressed in future studies; the duration of these effects should also be examined

452.    New, T., Curless, R., Morris, E., & Muckle, M. (1995). Care pathways. On the right path. Health Service Journal, 105(5473), 28.

453.    Kalbhen, J. (1995). Protocols--going down the clinical path. Hospitals & Health Networks, 69(19), 86.

454.    Rome, E. S., Moszczenski, S. A., Craighill, M., Goldmann, D. A., Schubert, P. S., Laufer, M. R., Emans, S. J., & Woods, E. R. (1995). A clinical pathway for pelvic inflammatory disease for use on an inpatient service. Clinical Performance & Quality Health Care, 3(4), 185-96.
Abstract: OBJECTIVE: (1) To create a guideline to improve care of adolescent patients diagnosed with pelvic inflammatory disease (PID); (2) to promote cost-effective, consistent care while minimizing delays and ensuring timely and appropriate use of laboratory tests and other interventions; and (3) to describe the process of the development and the implementation of a clinical pathway for PID. METHODS: The study involved the creation and piloting of a multidisciplinary, collaborative clinical pathway for uncomplicated PID on an inpatient service, and the development of a standardized form for analysis of demographics and variances from the pathway. The setting was an inpatient adolescent service at a children's hospital in an urban setting. All patients admitted with a clinical diagnosis of PID from April 1, 1993, to November 30, 1993, were followed up by means of the clinical pathway. All patients discharged with a diagnosis of uncomplicated PID in fiscal year 1992 (FY92: October 1, 1991, to September 30, 1992) were used as a comparison population. The main outcome measures included length of stay, charges per patient, timing of antibiotic administration, use of laboratory tests at admission and at 48 to 72 hours, and documentation of pathway variances. RESULTS: A clinical pathway was created by consensus during a period of several months. During implementation, 28 of 34 (82%) patients admitted by use of the pathway had a final diagnosis of PID; 23 of the 28 (82%) had uncomplicated PID. Variances from the pathway included missed rapid plasma reagins (RPRs) and laboratory tests that were not indicated. For uncomplicated PID, length of stay was reduced (p=.08) from a median of 4 days in FY92 (mean, 5.0 1 3.1 days; range, 2-15 days) to a median of 3 days in the study group (mean, 3.5 + 1.0 days; range, 2-4 days), with differences not reaching the level of significance. There were significantly more patients staying 5 days or longer in FY92 than in the study group (p<.03). Average charges per patient also decreased by 10% (median, $5,275 in FY92 to $4,919), although these results were not statistically significant. CONCLUSION: A clinical pathway for uncomplicated PID can be developed and implemented through a multidisciplinary, collaborative process, with ongoing use as a means of quality improvement and continuing education. Variances from the pathway highlight the need for ongoing education for health care providers. Downward trends in charges per patient and length of stay, although not significant, are encouraging; but they require longitudinal follow up with larger numbers of patients and analysis of outcomes.  (Abstract by: Author)

455.    Yasko, J. M. (1995). Clinical pathways: an interdisciplinary tool for high-quality, low-cost care. Innovations in Breast Cancer Care, 1(2), 25,38-40.

456.    Wujcik, D. (1995). Computerization of collaborative pathways. Innovations in Breast Cancer Care, 1(2), 30-2, 39-40.

457.    Tokarsky, J. M., & McLaughlin, M. A. (1995). Advantages of using clinical pathways for breast cancer patients. Innovations in Breast Cancer Care, 1(2), 26-9, 39-40.

458.    Tanli, S. H. (1995). Pathways, patient education improve satisfaction rates. Hospital Case Management, 3(10), 163-4.

459.    Spath, P. (1995). Identify ADRs early with risk assessment. Hospital Peer Review, 20(10), 150-1-suppl 3 p.

460.    Peters, D. A. (1995). Outcomes: the mainstay of a framework for quality care. Journal of Nursing Care Quality, 10(1), 61-9.
Abstract: To move toward quality care, it is important to understand all relevant terminologies and concepts. A conceptual framework is useful for organizing all the relevant practice components, such as professional standards, protocols, critical paths, and care plans. The article presents a framework for quality care that focuses on outcomes and defines and incorporates all the other essential elements that are used to reflect quality

461.    Pace, R. Y. (1995). The difference in dollars and sense: effective facility management for the outpatient cancer care center. Journal of Ambulatory Care Management, 18(4), 43-57.
Abstract: This article discusses the process to manage a modern cancer center effectively. The process is a continuous management cycle that begins with planning, then moves to implementation, and ultimately returns to planning. Within this cycle, a variety of management decisions and tools is analyzed.  (Abstract by: Author)

462.    Kennedy, M. (1995). Ten strategies for making clinical guidelines and pathways work. Quality Letter for Healthcare Leaders, 7(8), 2-12.

463.    Gunn, S. R., Hanisch, P., & Wood, D. (1995). CQI action team: responding to the detoxification patient. Joint Commission Journal on Quality Improvement, 21(10), 531-40.
Abstract: BACKGROUND: The management of detoxification patients is a complex interdisciplinary effort requiring involvement, cooperation, and understanding from staff at all levels of the facility. In 1992-93, alcohol-related diagnoses were the highest admission diagnosis at the Royal C. Johnson Veterans Affairs Medical Center (VAMC). Yet only 44% of the detoxification patients admitted to the VAMC were placed in beds specifically designed for detoxification. Initially, the action team believed that the issues were apparent and that the problems were the result of uncooperative and noncompliant providers who were not following established policy. METHODS AND RESULTS: Data analysis of admission and discharge trends, laboratory results, and bed census revealed discrepancies with several widespread myths held by local health care workers. These misperceptions and attitudes often interfered with treatment. CONCLUSIONS: Recommended changes included the development of a clinical pathway for the detoxification patient, implementation of an alcohol withdrawal assessment tool to manage and treat the patient at risk for experiencing alcohol withdrawal, and hospitalwide education on management of the detoxification patient

464.    Engstrom, C. A. (1995). Clinical pathways and continuous quality improvement in ambulatory care for patients with advanced breast cancer. Innovations in Breast Cancer Care, 1(2), 41-3, 39-40.

465.    Conrad, K. J., & Tokarsky, J. M. (1995). Patient guides to recovery... information about clinical pathways. Innovations in Breast Cancer Care, 1(2), 33-34, 39-40.

466.    Bartis, J., & Maljanian, R. (1995). Higher admissions lead to new vaginal hysterectomy path. Hospital Case Management, 3(10), 155-8.

467.    Schuckman, P. (1995). N.J. hospitals team to build pathways database open to competitors. Healthcare Systems Strategy Report, 12(20), 11.

468.    Pearson, S. D., Polak, J. L., Cartwright, S., McCabe-Hassan, S., Lee, T. H., & Goldhaber, S. Z. (1995). A critical pathway to evaluate suspected deep vein thrombosis. [Review] [36 refs]. Archives of Internal Medicine, 155(16), 1773-8.
Abstract: Uncertainty regarding the optimal evaluation of suspected deep vein thrombosis (DVT) results in wide variations in practice, even within the same institution. To address variation in practice while maximizing the efficiency and quality of care, our institution developed a critical pathway guideline for the emergency department evaluation of patients suspected of having DVT. We present the critical pathway and the clinical rationale underlying its recommendations. The critical pathway was developed by a multidisciplinary team using chart review of practice at our institution, benchmarking at other institutions, and review and discussion of the medical literature. Consensus was achieved for the selection of ultrasound as the primary imaging test for all patients and for recommending initial doses of heparin sodium that are higher than the current norm at our institution to reduce the length of time required to achieve therapeutic anticoagulation. A total time for patient evaluation of 5 hours or less was established as the target. Controversy arose in two key areas: (1) the treatment of patients with normal ultrasound scans when high clinical suspicion for DVT exists and (2) the evaluation and treatment of suspected isolated calf-vein DVT. In its final form, the critical pathway recommendations seek to balance the benefits of standardization with the prerogatives of physicians to make decisions tailored to individual patients. [References: 36]

469.    Wilbur, M., & Huff, H. (1995). Critical pathway for the continent urinary diversion. Journal of Urological Nursing, 14(3), 1095-1101.

470.    Bensley, D. C., Watson, P. S., & Morrison, G. W. (1995). Pathways of coronary care--a computer-simulation model of the potential for health gain. IMA Journal of Mathematics Applied in Medicine & Biology, 12(3-4), 315-28.
Abstract: A computer-simulation model of the need for cardiology services is described. The model simulates the potential for health gain, in terms of a fall in mortality, determining the effect of alterations in prevention and treatment rates. The model was initially developed from a pathways-of-care flow chart, which originated from a working group consisting of a consultant cardiac surgeon, cardiologists, and public-health physicians, together with statisticians and an operational-research analyst. The original purpose of the model was as a communication tool, to help nonclinicians to have a better understanding of how and why doctors work as they do, but it has since been developed for use in setting and meeting health targets. It enables quantification of the effects of changing different combinations of key variables over time. It is designed to answer 'what if?' questions of the type 'What would the effect of a 10% reduction in the incidence of angina be on the number of deaths, angiograms, angioplasties, and coronary-artery bypass grafts. The model has been made available in a form which only requires a Lotus 123 spreadsheet package to enable it to run, and it is designed to be easy to use with the assistance of simple two-key commands throughout. The model has been used by district health authorities to calculate the response required in their own local areas to achieve targets for the year 2000

471.    Zander, K. (1995). Evolving mapping and case management for capitation. Part I: the infrastructure solution. New Definition, 10(3), 1-2.

472.    Pouliot, S. (1995). Critical pathways and the health care access manager on the edge of technology. NAHAM Management Journal, 22(2), 20-24.

473.    Peruzzi, M., Ringer, D., & Tassey, K. (1995). A community hospital redesigns care. Nursing Administration Quarterly, 20(1), 24-6.
Abstract: In response to professional and societal forces, Albany Memorial Hospital redesigned patient care services. Funding as a New York State Workforce Demonstration project afforded the organization the resources to study components such as decentralization of services, case management, and reallocation of work to new or expanded roles. Subsequent changes in skill mix were associated with improved or unchanged quality indicators and satisfaction levels. Cost savings were demonstrated by adjusted labor costs and continue through present housewide use of caremapping. Although the process requires tremendous time and energy, the outcomes clearly justify the investment

474.    Lucas, C. M., Dierks, E. J., & Parker, N. (1995). Creating a practice partnership: a clinical application of case management. Advanced Practice Nursing Quarterly, 1(2), 49-63.
Abstract: Using the framework of case management, a team partnership was developed for the head and neck surgery population undergoing reconstruction with free tissue transfers ("free flaps"). The focus of the partnership was to improve care coordination from surgery scheduling through discharge. Practice agreements were negotiated, pre-printed on a clinical path, and further supported by pre-printed physician's orders, teaching materials, and a variance tracking tool. In the 6 months since implementing this partnership, patients have recovered more quickly, reducing length of stay by 25% and costs by 15% to 20%

475.    Aspling, D. L., & Lagoe, R. J. (1995). Development and implementation of a program to reduce hospital stays and manage resources on a community-wide basis. Nursing Administration Quarterly, 20(1), 1-11.
Abstract: The study describes an effort to reduce hospital stays and limit the use of expensive resources in the metropolitan area of Syracuse, New York. The program included the implementation of clinical pathways for a number of surgical procedures and medical diagnoses. The effort involved the identification of specific resource variables in a wide range of clinical disciplines. The program was important because it focused on cooperative efforts at length of stay and resource reduction by the staffs of all of the hospitals within a common service area

476.    Thompson, D. G., & Maringer, M. (1995). Using case management to improve care delivery in the NICU. MCN, American Journal of Maternal Child Nursing, 20(5), 257-60.
Abstract: A comparison study demonstrates that length of stay and average costs decrease for high-risk infants, while quality of care is strengthened.  (8 ref)

477.    Patton, M. D., & Schaerf, R. (1995). Thoracotomy, critical pathway, and clinical outcomes. Cancer Practice, 3(5), 286-94.
Abstract: Using a multidisciplinary critical pathway for chest surgery, the staff of Saint Joseph Medical Center (Burbank, California) and its physicians developed a strategy leading to improved patient outcomes with reduced overall costs. On referral from the surgeon's office, the multidisciplinary team, consisting of a clinical nurse specialist, physical therapist, and respiratory therapist, meet with the patient. The education that follows includes discussion of the surgical procedure, intubation, incentive spirometry, coughing, deep breathing, early ambulation, use of patient-controlled analgesia, chest physiotherapy, transfusion options, and evaluation of health status. A few days later, the patient undergoes the thoracoscopy-assisted thoracotomy. The success of the outcome-driven critical pathway can be related to several factors: (1) close coordination between the surgeon's office and hospital; (2) intensive preoperative education that decreases patient's anxiety and increases his or her ability to participate in recovery; (3) patient-controlled analgesia, nerve blocks, non-narcotic analgesia, and preemptive rehabilitation, which limit the risk for complication; and (4) thoracoscopy, which limits the surgical morbidity commonly affiliated with thoracotomy. The pathway, used for 160 patients during the past 2 years, has shown dramatic results related to reducing morbidity, practice variation, delay, and total overall cost

478.    Gorbien, M. J. (1995). Clinical pathways: too hard a course for complex patients? Continuum (Chicago), 15(5), 1-3-6.

479.    Claussen, D. W., & Pickering, P. (1995). A clinical pathway for endoscopy. Gastroenterology Nursing, 18(5), 182-5.
Abstract: The purpose of this article is to describe the development and use of a clinical pathway in an endoscopy setting. The goal was to incorporate all of the established practices of each discipline--nursing, medicine, admissions, laboratory, radiology, and others--without changing their practice models. The clinical pathway is the framework for all the activities in the management and practice of the unit, including the nursing standard of care, nursing competency-based practice, hospital policy and procedures, quality improvement, risk management, and physician preference

480.    Bryant, M. R. (1995). Cabinet on research. Critical pathways: what they are and what they are not. A two-part article: optimal care paths. Tar Heel Nurse, 57(5), 18-9.
Abstract: Critical pathways were the topic of an educational session sponsored by the Cabinet on Nursing Research at the 1994 NCNA convention. Marcella Bryant described the importance of critical path ways in today's health care environment Janice Janken discussed the need for critical pathways to be research-based. Participants at the session evaluated the information as timely and raising important issues for nurses to consider in our rapidly changing health care arena. Summaries of their presentations will be presented here and in a future Tar Neel Nurse.  (3 ref)

481.    Baron, E. J. (1995). Quality management and the clinical microbiology laboratory. Diagnostic Microbiology & Infectious Disease, 23(1-2), 23-34.
Abstract: Quality management in today's health care environment requires a fresh approach. Laboratories that have traditionally directed their efforts toward meeting the needs of physicians must now also satisfy the needs of society, the greater public health, and the agency's administrators. Technical advances must today be considered in the context of patient care cost-effectiveness or final outcomes. Examples of strategies for improving quality in the laboratory, such as seeking input from all individuals involved in interpreting or using laboratory test results, forming multidisciplinary committees for development of critical pathways, issuing surveys for assessing the level of satisfaction of the laboratory's customers, and providing visual feedback of the results of activities, are described

482.    Turner, L. J. (1995). Putting patient education on a new path. RN, 58(9), 42-4.
Abstract: Here's how to transform a critical pathway into a preop teaching tool in patient-friendly language.  (2 ref)

483.    Stahl, D. A. (1995). Critical pathways in subacute care. Nursing Management, 26(9), 16-8.

484.    Schuckman, P. (1995). N.J. hospitals band together to create critical pathways database. Report on Healthcare Information Management, 3(9), 1-2.

485.    Nelson, M. F., & Christenson, R. H. (1995). The focused review process: a utilization management firm's experience with length of stay guidelines. Joint Commission Journal on Quality Improvement, 21(9), 477-87.

486.    Miller, J., Newton, V., & Havercroft, J. (1995). Nursing patients through "pathways of care". Professional Nurse, 10(12), 759-62.
Abstract: In response to the increased amount of paperwork that nurses had to complete, staff in one surgical unit introduced a "Pathways of Care" scheme in which standard documentation relating to each stage of the recovery process is used for all patients.  (3 ref)

487.    Meskenas, S., Daniels, M. J., & Moore, C. (1995). Comfort care path strengthens support for terminally ill. Hospital Case Management, 3(9), 139-42.

488.    Lindstrom, C. C., Laird, J., & Soscia, J. (1995). High quality and lower cost: they can coexist. Seminars for Nurse Managers, 3(3), 133-6.
Abstract: The need to control costs must be balanced with consumers' demands for high quality in their health care. An integrated approach that uses a multidisciplinary team, a case manager, and a clinical path to improve the quality of patient care offers one method by which both goals may be achieved. The report details the results of a case study in which these three elements were applied to the care of patients undergoing total hip replacement surgery. Results included a length of patients' stay of 3.92 days, cost reduction of $667 per patient in direct costs, no reported cases of readmission for complications during the 2 year process, reductions in length of stay for patients referred to extended care facilities, and a shortened period in home health services. These results are attributed to extensive use of prior screening for all patients by multiple care disciplines, better patient education processes before admission and surgery, improved communication between team members on patient progress, and coordination of care across the continuum

489.    Hill, P. D., Andersen, J. L., & Ledbetter, R. J. (1995). Delayed initiation of breast-feeding the preterm infant. Journal of Perinatal & Neonatal Nursing, 9(2), 10-20.
Abstract: It is well documented that mother's milk is the best source of nutrition for the preterm infant. However, mothers of preterm infants face obstacles during the early stages of the breast-feeding experience. This study examined the experiences of 13 mothers whose preterm infants initiated suckling at the breast on day 14 or later after birth. Eight weeks after delivery, six infants were exclusively receiving mother's milk, four were receiving mother's milk and formula, and three infants had been weaned entirely from mother's milk. Some of the problems encountered by these mothers may have been averted with input from health professionals with special knowledge in breast-feeding the preterm infant. A clinical pathway for breast-feeding preterm infants is presented

490.    Hawkes, W. G. (1995). Bibliography: critical paths. Journal of the New York State Nurses Association, 26(3), 28.

491.    Graham, M. J., Pettus, T., & Klava, S. (1995). Subacute care. Critical pathways link services to outcomes. Provider, 21(9), 31-2.

492.    Goldfarb, S., Brailer, D., & Katz, F. (1995). Proving the link between outcomes and resource utilization. Medical Interface, 8(9), 79-82-84.
Abstract: Medical practice profiling is a popular way of helping to reduce variation in resource utilization among providers in managed care organizations. Usually, these programs take into account severity of illness, patient demographics, and so forth, but rarely are clinical practice patterns linked with outcome. The authors offer information about an information system-based program that attempts to do just that.  (Abstract by: Author)

493.    Gibbs, B. F., Guzzetta, V. J., & Furmanski, D. (1995). Cost-effective carotid endarterectomy in community practice. Annals of Vascular Surgery, 9(5), 423-7.
Abstract: The purpose of this study was to compare hospital charges for carotid endarterectomy on a surgeon-specific basis. The cost of carotid endarterectomy is influenced by preoperative evaluation, operating time, use of the intensive care unit, length of hospital stay, and surgical results. Length of stay and average hospital charges for 18 doctors performing 344 carotid endarterectomies at three hospitals were analyzed. Outcome data were also reviewed. The results demonstrated a wide variation in hospital charges among surgeons. Surgeons using the most cost-effective measures achieved comparable or superior outcomes. In an era of managed care, severe cost constraints mandate that surgeons perform similar studies in their own communities so that cost-effective clinical pathways can be developed. With the use of appropriate guidelines, carotid endarterectomy can be performed at relatively low cost without sacrificing quality

494.    Gaston, M. H., & Moody, L. E. (1995). Improving utilization of breast and cervical cancer screening in your office practice. Journal of the National Medical Association, 87(9), 700-4.
Abstract: It has been well documented that early detection and early intervention for breast and cervical cancer saves lives. However, the challenge is to ensure that physicians' practices are effective in implementing the standard guidelines for screening and that all women are screened and undergo appropriate follow-up. Early detection and intervention are imperative since African-American women are twice as likely as European-American women to die from breast cancer even though the incidence of breast cancer is lower. African-American women have fewer mammograms and are being diagnosed later after metastases have occurred. Studies also show that women are more likely to have mammograms if their physicians so advise. However, the most common reason women give for not obtaining mammograms is, "My doctor never recommended it." By using a simple critical path analysis tool to systematically evaluate an office practice and by implementing practical, simple principles, a physician can increase utilization of breast and cervical cancer screening

495.    Fleschler, R. G., & King, B. P. (1995). Perinatal outcomes management: balancing quality with cost. Journal of Perinatal & Neonatal Nursing, 9(2), 21-8.
Abstract: As flexibility and change become the only constants in health care delivery, providers are seeking improved methods for delivering quality, cost-effective services. Perinatal care is no exception. Length of stay is decreasing for obstetric patients, and the challenges of providing quality care are great. Outcomes management uses outcomes measures to improve clinical and functional results while better utilizing resources. Critical pathways and variances from that pathway are analyzed for opportunities to improve care and quality. Quality indicators are then derived from the variance data. The women's services outcomes manager, a new role, identifies and resolves quality issues

496.    De Jong, R. L. (1995). This path has pictures. RN, 58(9), 44-5.
Abstract: This author took the idea of using critical pathways for patient education one step further.  (2 ref)

497.    Burns, J. M., Tierney, D. K., Long, G. D., Lambert, S. C., & Carr, B. E. (1995). Critical pathway for administering high-dose chemotherapy followed by peripheral blood stem cell rescue in the outpatient setting. Oncology Nursing Forum, 22(8), 1219-24.
Abstract: PURPOSE/OBJECTIVES: To explain the rationale and process of outpatient critical pathway development for sequential high-dose chemotherapy followed by peripheral blood stem cell transplantation. DATA SOURCES: Published books and journal articles. DATA SYNTHESIS: Complex treatment for patients with metastatic breast cancer is shifting to the outpatient area. To make this therapy safe and cost effective, a process for monitoring this type of outpatient care needs to be developed. CONCLUSIONS: Collaboration with a multidisciplinary team is important in ensuring quality of care for complex outpatient treatment protocols. Critical pathway development can serve as a road map for delivering this care. IMPLICATIONS FOR NURSING PRACTICE: As team leaders, nurses should oversee the critical pathway development and implementation. Nurses also should maintain their role of patient advocacy through monitoring pathway compliance

498.    Weiman, M. G. (1995). Case management. A means to improve quality and control the costs of cure in children with acute myelogenous leukemia. Journal of Pediatric Hematology/Oncology, 17(3), 248-53.
Abstract: Acute myelogenous leukemia (AML) is a costly disease to treat, as patients experience many hospital stays secondary to chemotherapy, the side effects of treatment, and bone marrow transplantation. The trend for some medical centers has been to reduce costs and increase quality through case management. The case manager uses critical pathways and one-on-one interaction to facilitate the patients' progress through the hospital system and to decrease delays and duplication. CONCLUSION: Case management and critical pathways could become an indispensable tool for the management of pediatric patients with cancer

499.    Trofino, J. (1995). Transformational leadership in health care. Nursing Management, 26(8), 42-9.
Abstract: One of the most important evolutionary forces in transforming health care is the shift from management to leadership in nursing. The transformational leader will be the catalyst for expanding a holistic perspective, empowering nursing personnel at all levels and maximizing use of technology in the movement beyond even patient-centered health care to patient-directed health outcomes.  (29 ref)

500.    Spath, P. (1995). How to manage your outcomes more effectively. Hospital Peer Review, 20(8), 120-4.

501.    Schuckman, P. (1995). Clinical paths take center stage as N.J. facility prepares for the future. Report on Healthcare Information Management, 3 (8), 9-11.

502.    Reinhart, S. I., Anderson, F. D., Clay, P. A., Patrician, P. A., & Maloney, J. P. (1995). Managed care at Eisenhower Army Medical Center: an initial experience. [Review] [23 refs]. Military Medicine, 160(8), 384-8.
Abstract: Managed care is receiving a great deal of attention in the health care industry. In today's cost-conscious economic environment, managed care has been developed in an attempt to maximize quality of health care while minimizing the cost of providing that care. The purposes of this article are to (1) review the principles of clinical case management; (2) describe the implementation of clinical case management and critical paths at Dwight David Eisenhower Army Medical Center; (3) elaborate on successful strategies employed; and (4) address difficulties encountered. Finally, the study that is currently underway at the facility will be briefly discussed. [References: 23]

503.    Phillips-Harris, C., & Fanale, J. E. (1995). The acute and long-term care interface. Integrating the continuum. [Review] [24 refs]. Clinics in Geriatric Medicine, 11(3), 481-501.
Abstract: Acute and long-term care traditionally have been distinctly different health care services, separated by reimbursement mechanisms, types and numbers of providers, and overall approach to the management of chronic illness. Considerable effort has been made of late, primarily due to financial incentives, to integrate these two levels of care into a "seamless" continuum. Barriers to such an integration process must first be identified. Physician and other health care providers will need to develop the tools and resources necessary to manage frail, chronically ill patients in settings other than the traditional acute care hospital, as well as to develop information systems that allow communication to flow easily between all levels of care. As subacute or transitional care becomes a central piece of a health care delivery system, those tools become critical to the provision of quality, integrated care. [References: 24]

504.    Patton, M. D., & Katterhagen, J. G. (1995). Cancer care critical pathways: implementing a successful program. Hospital Technology Series, 14(9), 1-50.
Abstract: Change in any form creates stress on systems, yet there is growing awareness within the health care field that change must come as cost-conscious insurers and employers refuse to pay for overextended processes that grew out of the charge-based reimbursement era. Short-term solutions, such as discounted charges and staff cuts, are not the answer when the entire system needs an overhaul. The cost of care escalates and the quality of patient care suffers because the system lacks the appropriate mechanisms to reduce redundancy, eliminate waste, improve effectiveness, and provide the high-quality care that a community expects from its hospital. The outcomes-based critical pathway approach discussed here has been used with great success and differs from classic pathway writing in that only elements related to the specific outcome are allowed on the order set. The critical pathway process starts with a review of historical patient records, which yields information about both historical practice patterns and the provider team. Using this information, a work group is formed and patient goals or outcomes are established for the population in question. The entire system is informed and educated, with special attention given to the medical staff, clinical outcome and financial data are developed and provided to individuals in the process, and a feedback loop is established. Cancer care is an attractive target for critical pathways, because it is an area with high cost and expensive technology, and physician practice patterns and patient outcomes can vary widely. On the flip side, the historically multidisciplinary nature of cancer care offers a good starting point for the collaborative culture needed to successfully implement critical pathways. When done right, critical pathways can decrease morbidity and mortality, reduce redundancy and cost, increase patient satisfaction, and improve patient outcomes. Shifting practice and eliminating variation in practice patterns, without regard to best practices and outcomes, could leave an organization compromised by group norms. Few things will sustain the energy needed to keep the hospital culture moving forward. This is not to say that it cannot be done, because it can. The critical pathway process has noticeable energy cycle levels--periods of high energy and low energy. The two hospitals discussed here reveal their painstaking effort to maintain and invigorate a process that would rather wait another day. Carefully selected work group members, reminders to keep individuals from returning to old practice habits, and an established, firm connection between cost and quality will help carry an organization through periods of low energy.(ABSTRACT TRUNCATED AT 400 WORDS)  (Abstract by: Author)

505.    McKeon, T. (1995). Activity-based cost management: a tool for survival. Journal of Home Health Care Practice, 7(4), 69-75.
Abstract: The measurement of processes and costs is necessary to demonstrate quality to the purchasers of home health services. An activity-based cost management (ABCM) system will provide the vehicle to link process cost to payers, product lines, clinical pathways, and agency processes. Use of the output from an ABCM system will facilitate process improvement and the development of organizational efficiency.  (2 ref)

506.    Koch, M. O. (1995). Cost-efficient radical prostatectomy. Seminars in Urologic Oncology, 13(3), 197-203.
Abstract: Radical retropubic prostatectomy is an easily standardized procedure with reproducible outcomes. Care has been standardized at our institution through the use of a collaborative care approach that defines the optimal care and outcomes for the ideal patient on a daily basis. This approach is based on an objective evaluation of the available medical literature. With this program, hospital charges have been reduced by 41% and hospital stay has been reduced to 2.9 days. Surgical outcomes have been excellent with low morbidity rates and excellent patient acceptance. Collaborative care programs for health care provide a comprehensive approach that allows for the delivery of cost-efficient care, which is supportive of the patient and allows continual refinement in care based on objective analysis of outcomes

507.    Klee, W. B. (1995). For the times they are a-changin'. Hospital Materiel Management Quarterly, 17(1), 22-7.
Abstract: Today, as we deal with managed care, vertical integration, mergers, new technologies, diagnosis related groups, stockless or just-in-time distribution, capitated contracts, consignment, health maintenance organizations, preferred provider organizations, total quality management/continuous quality improvement, reengineering, federal regulations, care mapping, patient focused care, and so forth, it is obvious that the only thing that is constant is change. "For the times they are a changin."  (Abstract by: Author)

508.    Karcz, A. (1995). Critical pathways to utilization review. Administrative Radiology, 14(8), 23-5.

509.    Hauser, S. P. (1995). Case management of the kidney transplant recipient. Anna Journal, 22(4), 369-74.
Abstract: Cost and quality outcome measures were evaluated after the first 2 years following initiation of the case management model of care for kidney transplant recipients. Guided by implementation of a clinical pathway, average total length of stay decreased from 12.7 to 9.2 days over a 2-year period. Average total charges increased by 4%, due to a market adjustment in the standard acquisition fee charged to process the donor organ. Compliance, measured by a self-report tool, revealed perceived difficulty in 2 of 9 domains surveyed: diet and exercise

510.    Guthrie, S. (1995). Physician-driven depression path standardizes care. Hospital Case Management, 3(8), 123-6.

511.    Grant, E., Newton, M., & Moore, S. (1995). Keeping patients on the right track. Nursing, 25(8), 57-59.

512.    Graham, M. J., Pettus, T., & Klava, S. (1995). Outcomes assessment in subacute programs. Provider, 21(8), 39-40.

513.    Gilbert, M., & Counsell, C. M. (1995). Coordinated care for the SCI patient. Sci Nursing, 12(3), 87-9.
Abstract: The delivery of quality patient care in a timely, cost-effective manner is of utmost importance in health care settings. In an attempt to promote continuity and coordination of care, appropriate utilization of resources, and increased patient and health care provider satisfaction, a coordinated care system of patient care delivery was implemented for the spinal cord injured patient. Coordinated care is a multi-disciplinary approach that focuses on achieving patient outcomes within effective time frames which have been established by all members of the health care team involved in the treatment of the SCI patient. Integral to the concept of coordinated care is the utilization of a critical path and variance tracking and analysis. A critical path is a multidisciplinary plan which identifies the time frame in which key events and patient outcomes should occur during an episode of care in order to achieve an optimal use of resources and length of stay. Variance tracking is the comparison of the actual care delivered with the expected plan and the identification of reasons why the care differed

514.    George, E. L., & Large, A. A. (1995). Reducing length of stay in patients undergoing open heart surgery: the University of Pittsburgh experience. AACN Clinical Issues, 6(3), 482-8.
Abstract: The clinical pathway, one component of the case management model, was implemented at one university medical center in the coronary artery bypass surgical group. In this article, the authors describe the development, use, and evaluation of the clinical pathway. The role of the advanced nurse practitioner as the case manager is discussed. The initial data base created by the case manager includes patient demographics, daily progress, length of stay, charges, discharge disposition, and readmissions within 15 days. Data collected on all patients undergoing coronary artery bypass graft surgery from July 94 to October 94 are reported and compared with the benchmark set with the development of the clinical pathway. Strategies developed for future improvement in the clinical pathway process and data management are identified

515.    Costello, M. M., & Murphy, K. M. (1995). Clinical guidelines: a defense in medical malpractice suits. Physician Executive, 21(8), 10-2.
Abstract: Clinical pathways, or practice guidelines, have been gaining wider acceptance from physicians and hospitals seeking to constrain increasing operating costs for inpatient care. The authors believe that properly developed and agreed upon guidelines can also be used in certain cases as appropriate standards of care in determining if medical malpractice has occurred. Adherence to the guidelines could then be asserted by defendants as an affirmative defense in a medical malpractice suit.  (Abstract by: Author)

516.    Collier, P. E. (1995). Are one-day admissions for carotid endarterectomy feasible? American Journal of Surgery, 170(2), 140-3.
Abstract: BACKGROUND: In 1990, a clinical pathway for streamlining the care of patients undergoing elective carotid endarterectomy was developed and tested at our institution. This consisted of extensive preoperative patient education in the surgeon's office, outpatient arteriography (now performed only on select patients), same-day admission, regional anesthesia when possible, selective use of the intensive care unit (ICU), and early discharge in the first postoperative day when feasible. PATIENTS AND METHODS: Between January 1, 1991 and June 30, 1994, 186 patients were entered into the protocol. Twenty-six percent of the patients were asymptomatic, while 74% had either transient symptoms or a prior stroke; 13% were operated on under general anesthesia. RESULTS: Three (1.6%) patients developed neurologic complications: 1 minor stroke, 1 transient ischemic attack, and 1 intracerebral hematoma; and 18 (10%) patients required the ICU postoperatively. On the first postoperative day, 157 patients were discharged. Average operative time was 48 minutes (range 39 to 61). Average length of stay (LOS) was 1.27 days. One death occurred on the 28th postoperative day from cardiac causes, and there were no hospital readmissions. Cost savings were over $3,000/patient when compared to the diagnosis-related group reimbursement. Because of the distribution of the data, statistical analysis was not feasible; however, several trends were clear. Neurologic complications, admission to the ICU, and increasing LOS all diminished the cost efficiency of carotid endarterectomy. Type of anesthesia and the use of a shunt or patching did not affect cost. Clearly, increasing the length of operation would also decrease cost efficiency. CONCLUSIONS: Adoption of the clinical pathway presented here is feasible in any institution. One-day admission for patients undergoing carotid endarterectomy has been shown to be safe, highly cost-effective, and results in more efficient use of scarce resources, such as the ICU

517.    Burchiel, R. N. (1995). Does perioperative nursing include caring? AORN Journal, 62(2), 257-9.
Abstract: Does perioperative nursing include caring? Does it show evidence of a theoretical base of caring? Yes, most definitely. We touch; we listen; we hold; we act as advocates. The challenge is to articulate these actions in our body of knowledge and practice. What would an outcome statement on perioperative caring look like? As perioperative critical paths are developed, how will perioperative caring outcomes be expressed? These are the challenges perioperative nurses must meet to demonstrate the necessity of the perioperative nursing role in providing humanistic care in the OR

518.   Baldry, J. A., & Rossiter, D. (1995). Introduction of integrated care pathways to a neuro-rehabilitation unit. Physiotherapy, 81(8), 432-4.
Abstract: Integrated care pathways have been used at the Neuro-rehabilitation Unit of the National Hospital for Neurology and Neurosurgery, London, since 1993. This descriptive paper outlines their introduction and use to date, and highlights some of the issues involved and benefits achieved.  (2 ref)

519.    Tucker, S. M., & Cramer, D. (1995). Interdisciplinary care paths: creation to implementation. Nursing Quality Connection, 5(1), 6-7.

520.    Lee, S. (1995). Clinical pathways for case management. Continuing Care, 14(6), 12-7.
Abstract: Clinical pathways define a series of events that are expected to occur within an anticipated time, which sequence and monitor a patient's progress and treatment. They are used to project an individual's response to care and prospectively address alterations to these goals or outcomes.  (Abstract by: Author)

521.    Holle, M. L., Rick, C., Sliefert, M. K., & Stephens, K. (1995). Integrating patient care delivery. Journal of Nursing Administration, 25(7/8), 32-37.
Abstract: Concepts of coordinated care, ease management, and continuous quality improvement were applied by a medical center nursing service to improve continuity and coordination of patient care between inpatient and outpatient programs. Quality and cost outcomes are presented for a pilot project with a total hip replacement population

522.   Gogola, M. (1995). A joint hospital/vendor project brings CQI and point-of-care technology to home care. Computers in Nursing, 13(4), 143-50.
Abstract: A joint project team consisting of personnel from Parkview Episcopal Medical Center, Pueblo, Colorado, and Patient Care Technologies, Atlanta, Georgia, a software vendor, codeveloped a point-of-care based system of electronic patient records and administrative data capture for home health care. Well established continuous quality improvement techniques, in use at Parkview for approximately 6 years, guided the development project and the subsequent alpha and beta testing of the system. Significant results to date include an overall productivity gain approaching 20%, the potential to increase annual home care revenue $876,000 with the same staffing level, and an 83% reduction in billing errors. Although not directly measured as a part of the study, the project team believes the quality of charting has improved because it is now done at the point-of-care in the home rather than in the office--some period of time after care is delivered. Anticipated future development includes integration of the home care clinical record with the hospital's clinical data repository and explicit support of critical pathways

523.    Bissell, M. G., Bernstein, L. H., Sazama, K., Wright, D. L., Markin, R. S., & Martinez, R. (1995). Clinical pathways: Part I. Panel discussion. Clinical Laboratory Management Review, 9(4), 327-9.

524.    Wilson, D. E., Noseworthy, T. W., & Grace, M. G. (1995). Caremap management in low-severity surgery: a comparative trial. Journal of the American College of Surgeons, 181(1), 49-55.
Abstract: BACKGROUND: Caremap management refers to the management of defined patient groups using multidisciplinary clinical guidelines developed through literature review and expert opinion. STUDY DESIGN: Using a prospective preintervention and postintervention comparison model, this controlled study compared caremap management and traditional treatment in patients undergoing inguinal herniorrhaphy. Preintervention (n = 141) and postintervention (n = 110) groups were compared for hospital length of stay, resource consumption, and outcomes. RESULTS: Patients cared for by caremap management compared with traditional treatment showed a significant reduction in average length of stay (0.6 compared to 1.6 days, p < 0.01). Laboratory testing decreased by 60 percent in the caremap management group relative to traditional treatment (p < 0.01) and standardization of medication profiles was achieved. There were no significant differences in readmission rate, reutilization of health care services, or complications. Patients in the caremap management group indicated a preference for additional length of stay. CONCLUSIONS: Caremap management offers the potential for achieving effective patient care while using resources efficiently. Further evidence is required to demonstrate that caremap management can fulfill the promise of improving health status outcomes in varied types of patients

525.    Springer, D. (1995). Pneumonia pathway gets OK for further LOS reduction. Hospital Case Management, 3(7), 107-10.

526.    Rubin, E. (1995). Critical pathways in the analysis of breast masses. Radiographics, 15(4), 925-7.

527.    Parker, S. H., Dennis, M. A., & Stavros, A. T. (1995). Critical pathways in percutaneous breast intervention. Radiographics, 15(4), 946-50.

528.    Newstead, G. M., & Weinreb, J. C. (1995). Critical pathways for the future: MR imaging and digital mammography. [Review] [40 refs]. Radiographics, 15(4), 951-62.

529.    Mosher, C. M. (1995). Putting pressure ulcers on the map. Journal of Wound, Ostomy, & Continence Nursing, 22 (4), 183-6.
Abstract: Critical pathways are effective tools to coordinate care, decrease length of stay, and increase communication among health caregivers. This article presents a critical pathway for pressure ulcer management. The pathway is designed for use in a variety of settings, including acute care, home care, and extended care, to monitor and describe wound status and treatment regimens

530.    Mendelson, E. B., & Tobin, C. E. (1995). Critical pathways in using breast US. Radiographics, 15(4), 935-45.

531.    Mendelson, E. B. (1995). 1994 plenary session: imaging symposium. Critical pathways in the management of breast disease: introduction. Radiographics, 15(4), 923-4.

532.    Irrgang, J. J., Delitto, A., Hagen, B., Huber, F., & Pezzullo, D. (1995). Rehabilitation of the injured athlete. Orthopedic Clinics of North America, 26(3), 561-77.
Abstract: The authors have presented basic guidelines and considerations for rehabilitation of the injured athlete. The use of various physical agents and therapeutic exercise in the rehabilitation of the injured athlete has been discussed. Clinical pathways for improving range of motion and muscle function and eliminating functional limitations and disability have also been presented. It should be remembered that rehabilitation of the injured athlete at any point in time may focus on any one or combination of these areas. The ultimate goal for rehabilitation of injured athletes is to return them to their prior level of sports activity. Athletes should be discharged from rehabilitation when they have achieved this goal or when no further improvement in their level of function can be expected. Individuals unable to return to their prior level of activity should be provided with alternate activities that they can continue to participate in to maintain an active lifestyle

533.    Edel, E. M. (1995). Perioperative education: a center of excellence. Seminars in Perioperative Nursing, 4(3), 188-91.
Abstract: The responsibilities and areas of accountability of the perioperative nurse are growing. The Perioperative Education department at St Luke's Episcopal Hospital in Houston, TX has developed creative methods of orientation, critical pathways, and continuing education to meet the expectations of staff competency for all patient care

534.    Booth, R. E. Jr. (1995). Critical care pathways in thromboembolic disease. Orthopedics (Thorofare, NJ), 18(Suppl ), 6-9.
Abstract: Critical Care Pathways are outlines of each day's expected interventions and treatments for a particular process. They are part of a larger concept of case management, as an extramural, multidisciplinary approach to a patient's problems, with details suitable to their personality and case. This constitutes the overall concept of managed care. Rather than DVT, this presentation focuses on thromboembolism. I think you'll see why I chose to emphasize this complication instead. Modern medicine has been turned upside down; the rules are different, expectations are different. I would suggest to physicians who are resisting the CCP concept that it may be your salvation as much as it is a paperwork torment. It's clearly a way to provide better care for your patients

535.    Bird, R. E. (1995). Critical pathways in analyzing breast calcifications. Radiographics, 15(4), 928-34.
Abstract: Screening-detected microcalcifications are responsible for more benign biopsy results than any other mammographic lesion. The management of these lesions comes at a large cost in terms of morbidity and dollars spent. Both costs and morbidity could be reduced by decreasing the number of surgical biopsies. This could be accomplished by increasing the positive biopsy rate and by substituting core needle biopsy for surgical biopsy when appropriate. To increase the positive biopsy rate, we need to improve the preoperative evaluation of microcalcifications. A scheme is presented for the mammographic evaluation of these microcalcifications and for the appropriate use of core biopsy in the management of these lesions

536.    Kane, R. L., & Kane, R. A. (1995). Long-term care. JAMA, 273(21), 1690-1.
Abstract: Long-term care has come to include both an acute component and the more traditional chronic component. The growth in subacute care has occurred under private prepaid auspices but has also been stimulated by changes in Medicare funding for hospitals. Quality improvement techniques, such as critical pathways, have been applied to long-term care

537.    Klein, D., & Campbell, A. (1995). The CQI pathway. Rehab Management, 8(4), 89-92-94-5.
Abstract: The use of CQI to identify issues, processes, and methods of quality management was a favorable learning experience for the Botsford General rehabilitation staff. They experienced improved interdepartmental communication and enhanced understanding of the roles and responsibilities of other disciplines, as well as the overall CQI process. The use of the CQI process accomplished the objective of decreasing the length of stay of patients with amputations by 6 to 8 days, thereby reducing costs. Use of flowcharting to outline a typical patient stay from admission to discharge helped to clarify potential problems, eliminate unnecessary steps, and reduce documentation time. Although rehabilitation services are currently exempt from diagnosis-related group application, in order to maintain cost efficiency and service effectiveness, it behooves us to continually track and stay in line with the competition. In light of anticipated health care reforms, the rehabilitation industry must be proactive in its management of service delivery with an emphasis on functional outcomes. Botsford General's success with using a critical pathway for the amputee program as part of a program evaluation system will lead to the development of critical pathways for additional diagnoses.  (Abstract by: Author)

538.    Villaire, M. (1995). Jill Ley: putting critical pathways on the map. Critical Care Nurse, 15(3), 106-113.
Abstract: Critical pathways promote multidisciplinary collaboration, enhance patient outcomes, and give patients responsibility for their own care. So what's not to like? Jill Ley, who heads the critical pathways program in the cardiac surgery department at California Pacific Medical Center in San Francisco, Calif, talks about how to implement pathways successfully, and the results of a major new survey on the use of critical pathways around the country

539.    Montague, T., Taylor, L., Martin, S., Barnes, M., Ackman, M., Tsuyuki, R., Wensel, R., Williams, R., Catellier, D., & Teo, K. (1995). Can practice patterns and outcomes be successfully altered? Examples from cardiovascular medicine. The Clinical Quality Improvement Network (CQIN) Investigators. [Review] [32 refs]. Canadian Journal of Cardiology, 11(6), 487-92.
Abstract: OBJECTIVE: To offer an attributive opinion of recent improvements in acute myocardial infarction (AMI) practice patterns and patient outcomes in the culture of an active health care research program. DATA SOURCES: Review of original clinical data from five sequential, consecutively enrolled, AMI patient cohorts at the University of Alberta Hospitals from 1987-93. DATA SYNTHESIS: Early cohorts had low use of trial-proven efficacious therapies for AMI, particularly among high risk older and female patients. Over time, there were continuous and marked increases in the use of efficacious therapies and decreased use of nonefficacious therapies, with a parallel decrease in mortality among high risk patients. CONCLUSIONS: In a large tertiary care hospital between 1987 and 1993 the use of evidence-based AMI therapy and survival in high risk patients significantly increased. The continuity and large size of these improvements in AMI practice patterns, compared with similar populations reported in the contemporary literature, suggest it is unlikely they were due to chance. Rather, intercurrent repeated measurement and reporting of key health care performance indicators, and initiation of explicit critical path AMI practice guidelines provide a more likely explanation. Future studies by a network of community and university investigators will test whether these findings are true for a broad AMI population and whether similar practice definition and improvement tools are effective for other cardiac problems, including the management of congestive heart failure. [References: 32]

540.    Marquette-Owens, K., & Trombley, M. (1995). Clinical pathways: a way to improve quality and reduce cost. Colorado Nurse, 95(2), 19.

541.   MacKenzie, M., & Waterman, M. (1995). Utilization of a clinical pathway in the care of the ambulatory cataract surgical patient. Insight, 20(2), 6-11.
Abstract: Rapid changes are occurring in healthcare today. Both customers and consumers of healthcare are demanding a change in the way business is being conducted. According to Smith (1993), healthcare organizations are being prompted to explore and implement systems which will enhance quality care as well as promote cost effective resource utilization. A notable change in recent years is the shift of ophthalmic surgical patients from inpatient to an ambulatory setting. This paper will focus on the implementation of a case management model for ophthalmic patients utilizing clinical pathways on an ambulatory unit. Emphasis will be on the provision of quality care resulting in positive patient outcomes

542.    Ley, J. (1995). Jill Ley: putting critical pathways on the map [interview by Michael Villaire] [see comments]. Critical Care Nurse, 15(3), 106-13.
Notes: Comment in: Crit Care Nurse 1996 Feb;16(1):17, 19-20

543.    Gray, B. B. (1995). What heals? What do nurses do that makes a difference. Critical Care Nurse, 15(3 Suppl ), 3-16.

544.   Gray, B. B. (1995). The patient-driven system... spreadsheets, called trajectories (similar to a critical pathway). Critical Care Nurse, 15(3), 144.

545.    Del Togno-Armanasco, V., & Wilson, A. C. (1995). HIV pathway progress based on intervals instead of days. Hospital Case Management, 3(6), 91-4.

546.    Dearmin, J., Brenner, J., & Migliori, R. (1995). Reporting on QI efforts for internal and external customers. Joint Commission Journal on Quality Improvement, 21(6), 277-88.
Abstract: BACKGROUND: In April 1993 the Methodist Hospital of St Louis Park, Minnesota, released its first internal quality report on outcomes and quality improvement (QI) initiatives. When a local television news reporter mentioned the report in a segment on health care quality, public interest led the hospital to launch an annual series of external quality reports in addition to its internal quality reports. When the eight-page external report was first released in 1994, consumer response was weak, but the report generated a strong response from the mass media, trade publications, the business community, and other health care organizations nationwide. DATA COLLECTION AND USE: Data on sentinel events and outcomes analysis of a variety of clinical and administrative functions have assisted in identifying opportunities for improvement. For example, the hospital monitors the five-year survival rate for patients with myocardial infarction. With the adoption of treatment with streptokinase, data indicated frequent hypotension. Increase of infusion from 30 to 60 minutes led to a decrease in hypotension. THE REPORTS: The external report included, in shorter and simpler form, almost all the sections in the internal report, such as QI activities (teams, training, critical paths), clinical outcome measures, community health, patient satisfaction, value, and accreditation. The indicators included in the external report were selected to minimize potential misinterpretation by public audiences. CONCLUSIONS: By increasing the visibility of QI within the hospital, the internal quality reports have helped generate further QI activity, and the external report augmented further positive publicity among the local health care press. The reports are proven effective tools for communicating the hospital's ability to sustain and improve the quality of its services over time

547.    Clark, R. E. (1995). The STS Cardiac Surgery National Database: an update. Annals of Thoracic Surgery, 59(6), 1376-80; discussion 1380-1.
Abstract: Since inception in 1990, The Society of Thoracic Surgeons (STS) National Cardiac Database has grown rapidly. More than 1,500 surgeons working in 706 hospitals have contributed more than one half million patient records. Geographic distribution of those participating is proportional to the number of centers performing heart surgery. The STS system is in use in all 49 states where centers are operating. There has been a significant decrease in length of stay for most patients having heart operations and a modest fall in coronary artery bypass grafting operative mortality from 3.7% to 3.3% over the past 3 years. Coronary artery bypass grafting case mix also is changing nationally as evidenced by a decline of 17% in the best-risk cases and concomitant increases in those with predicted risks of 5% to 10% and greater. New uses for local data in addition to self assessment and quality assurance include development of critical clinical pathways, support for managed-care group applications, and regional use. Minnesota has established a statewide STS system and Florida is soon to follow. The key to acceptance has been a peer-reviewed risk-stratification system that continues to be refined each year. Finally, a major effort will be made this year to increase the participation of general thoracic surgeons, particularly with respect to lung cancer

548.   Boutron, K. A., King, J., Matula, P., & Niznik, C. H. (1995). Clinical path coordinator: pulling it all together. Journal of Vascular Nursing, 13(2), 50-4.
Abstract: Institutions across the country are using different approaches to restructuring health care delivery systems. At Lehigh Valley Hospital collaborative practice was instituted to ensure the achievement of patient outcomes within appropriate time frames and with efficient use of resources. The role of the clinical path coordinator emerged from the collaborative practice model developed to manage the care of the patient with an abdominal aortic aneurysm. The step-by-step process for selecting, orienting, and implementing the role of the coordinator is discussed. Since the implementation of the coordinator role, patient satisfaction has been positive, length of stay and cost have decreased, and quality of care has improved for these patients

549.    Stevenson, L. L. (1995). Critical pathway experience at Sarasota Memorial Hospital. American Journal of Health-System Pharmacy, 52(10), 1071-3.

550.    Shane, R. (1995). Take the first step on the critical pathway. American Journal of Health-System Pharmacy, 52(10), 1051-3.

551.    Saltiel, E. (1995). Critical pathway experience at Cedar-Sinai Medical Center. American Journal of Health-System Pharmacy, 52(10), 1063-8.
Abstract: Critical pathways provide an excellent tool for promoting multidisciplinary efforts to develop optimal, cost-competitive plans for managing patient care. The pharmacy department can play a variety of roles in developing and implementing critical pathways. In advocating optimal drug selection and monitoring, pharmacists can help their institutions reduce costs while maintaining or improving quality of care

552.    Nelson, S. P. (1995). Critical pathways at University of Iowa Hospitals and Clinics. American Journal of Health-System Pharmacy, 52(10), 1058-60.

553.    Ivey, M. F., Armitstead, J. A., & Sangha, K. S. (1995). Critical pathways at University of Cincinnati Hospital. American Journal of Health-System Pharmacy, 52(10), 1053-8.

554.    Gouveia, W. A., & Massaro, F. J. (1995). Critical pathway experience at New England Medical Center. American Journal of Health-System Pharmacy, 52(10), 1068-70.
Abstract: At NEMC, critical pathway development started in areas in which we sought managed care contracts. Critical pathways are now developed by specific clinical services as they analyze their high-volume or high-cost case types. Our initial efforts have demonstrated the value of intervention by pharmacists in the analysis of the drug therapy aspects of pathways. To date, our critical pathway development has been focused on inpatient treatment and includes disease treatment methods as well as costs. In time, our PPI-guided development of critical pathways should reflect comprehensive treatment of patients with acute as well as nonacute disease. In this context, educating patients about their disease and drug therapy and monitoring compliance and overall drug treatment are vital to the successful implementation of critical pathways used in a capitated payment environment

555.    Gousse, G. C., & Rousseau, M. R. (1995). Critical pathways at Hartford Hospital. American Journal of Health-System Pharmacy, 52(10), 1060-3.

556.    Ramirez, J. A. (1995). Switch therapy in community-acquired pneumonia. Diagnostic Microbiology & Infectious Disease, 22(1-2), 219-23.
Abstract: In patients admitted to the hospital with community-acquired pneumonia, intravenous antimicrobials can be safely switched to oral administration when the patient shows evidence of early clinical improvement. In our institution, patients are switched to oral antibiotics when: (A) cough and respiratory distress are improving, (B) patient is afebrile for at least 8 h, (C) the white blood cell count is returning toward normal, and (D) there is no evidence of abnormal gastrointestinal absorption. Patients with respiratory infections of unknown etiology are switched to an oral antibiotic with the same spectrum of activity as the intravenous empiric antibiotic. Combining our prospective clinical studies, we have patient outcome data for more than 150 patients admitted to the hospital with community-acquired pneumonia, who were treated with switch therapy. The clinical cure rate was 99.3%. The total hospital savings for 1994 based on the 80 patients with community-acquired pneumonia who were treated with switch therapy was $114,080. Discontinuation of intravenous lines will decrease the patient's risk for local cellulitis, abscess formation, septic thrombophlebitis, line sepsis, and endocarditis. The early hospital discharge associated with switch therapy will decrease the patient's risk for other nosocomial infections such as urinary or respiratory tract infections. Switch therapy is associated with a clinical cure rate that is equivalent to conventional therapy. In the area of cost-effective use of antibiotics, switch therapy should be considered as one of the primary options for health care cost containment

557.    Lawson, R. D. (1995). Implementing an integrated program of resource management. Journal for Healthcare Quality, 17(3), 17-22-30.
Abstract: The physicians at Methodist Hospitals of Memphis have designed a program of resource management that has resulted in significant patient care cost savings while maintaining an excellent quality of care. The program combines methods of increasing physician awareness of cost issues, sharing physician utilization and quality data with them, and coordinating patient care through the use of multidisciplinary clinical pathways and case management. Our physicians, patients, nursing staff, and quality management personnel are enthusiastic about the program's positive effect on costs and improved quality patient care.  (Abstract by: Author)

558.    Johnson, K., & Proffitt, N. M. (1995). A decentralized model for case management. Nursing Economics, 13(3), 142-51, 165.
Abstract: Case management has been implemented in a variety of health care settings. The implementation of case management at one hospital, including rationale for selection and outcomes, is described here. A decentralized model emphasizing staff nurse control is recommended for hospitals with TQM and shared governance programs already in place.  (8 ref)

559.    Gallagher, C. (1995). Pediatric clinical path program development: project selection and "rollout". Journal for Healthcare Quality, 17(3), 4-10; quiz 10-16, 51.
Abstract: Criteria-based project prioritization is key to the rational development of a clinical path program. Implementation education that emphasizes a philosophy of cost-quality balance fosters multidisciplinary participation and program "rollout," or expansion. This article explains the selection of case types based on volume, cost, physician interest, resource use variability, market opportunity, and clinical homogeneity. Also described is how implementation is facilitated by educating physicians, nurses, and other clinicians about the relationship between clinical paths, collaboration, and quality improvement.  (Abstract by: Author)

560.   Cornwell, P. (1995). Contrasting designs of critical pathways. Journal of Burn Care & Rehabilitation, 16(3 Pt 1), 295-304; discussion 294.

561.    Connolly, M. L., Russell, M., & Reyna, C. (1995). Home care of the prostate cryosurgery patient. Todays Or-Nurse, 17(3), 25-36.
Abstract: 1. Through the use of the pathway process, variation in home care of the prostate cryosurgery patient is reduced in caregiver technique and efficiency of care delivery is improved. More importantly, patient outcomes are closely monitored and multidisciplinary continuity of care is promoted. The pathway helps ensure that appropriate resources are initiated and used in appropriate timeframes. 2. A patient version of the critical pathway, written in lay terminology, is given to patients to define their responsibilities in the care process. This method encourages patient participation in care. 3. The purpose of home care is to educate the patient about his disease process and treatment regimen, and encourage him to participate in his treatment and recovery. The prostatic cryosurgery pathway gives him an opportunity to be active in his care

562.    Schaffner, Y., & Rossi, S. (1995). The early maternal discharge clinical pathway: health care's wave of the future. Journal of Home Health Care Practice, 7(3), 66-70.
Abstract: With increasing demands from external sources, maternal child providers are facing the challenges of accurate and timely assessments. Documentation for both legalities and reimbursement can be accomplished through the clinical pathway. This article describes how one organization developed its pathways and how another developed its documents

563.   Musser, K., & Hendrickson, M. L. (1995). Universal demands don't hinder development of CM. Hospital Case Management, 3(5), 82-84.

564.    Krampf, L. (1995). Physician-led teams develop critical pathways. Or-Manager, 11(5), 28-30.

565.    Gibbs, B., Lonowski, L., Meyer, P. J., & Newlin, P. J. (1995). The role of the clinical nurse specialist and the nurse manager in case management. Journal of Nursing Administration, 25(5), 28-34.
Abstract: Nursing care management was introduced into the acute care hospital as an approach to counteract the numerous changes occurring in the healthcare environment negatively affecting patient care. The authors address the development of case management at Bergan Mercy Medical Center, Omaha, Nebraska, and the integration of the nurse manager and clinical nurse specialist into this model.  (9 ref)

566.    Gelinas, L. S., & Manthey, M. (1995). Improving patient outcomes through system change: a focus on the changing roles of healthcare organization executives. Journal of Nursing Administration, 25(5), 55-63.
Abstract: In this article, the authors report on a project that studied the impact of work redesign on the roles of hospital executives. Thirty-six in-depth interviews were conducted with executives from 13 VHA healthcare organizations that were considered excellent practice models in the area of work redesign. This report represents a broad, multidisciplinary perspective reflecting the ideas of various members of the healthcare management team. VHA hired Marie Manthey and Creative Nursing Management, Inc., to conduct the interviews in an objective manner and to assist with results interpretation

567.    Gartner, M. B., & Twardon, C. A. (1995). Care guidelines: journey through the managed care maze. Journal of Wocn, 22(3), 118-21.
Abstract: Home health care agencies face significant challenges as they respond to the changes in reimbursement for heath care services. In this era of "out of control" increases in costs for health services, health care managers must ensure the prudent allocation of health care dollars while maintaining adequate quality of services delivered. One method advocated to accomplish this goal is a change from a fee-for-service reimbursement system to a managed care model. The patient care pathway, a formatted time line for interventions and anticipated outcomes, is an important tool for health care agencies in responding to the demands of the managed care model. This article describes the development of a patient care pathway in one home health agency.  (6 ref)

568.    Evangelista, M. (1995). Transferable pathway benefits hospital, hospice. Hospital Case Management, 3(5), 75-8.

569.    Duncan, S. K., & Otto, S. E. (1995). Implementing guidelines for acute pain management. Nursing Management, 26(5), 40, 44-47.
Abstract: The article addresses the implementation of the Agency for Health Care Policy and Research (AHCPR) guidelines for acute pain management using a multidisciplinary approach. Results of the comprehensive program and the pilot project at St. Francis Regional Medical Center in Wichita, Kansas, are discussed.  (12 ref)

570.    Davis, J. T., Allen, H. D., Felver, K., Rummell, H. M., Powers, J. D., & Cohen, D. M. (1995). Clinical pathways can be based on acuity, not diagnosis. Annals of Thoracic Surgery, 59(5), 1074-8.
Abstract: The standardization of medical practice is gaining acceptance as a technique for controlling length of stay and hospital charges, while maintaining quality. Most clinical pathways address specific diagnoses or procedures, but we have developed a new approach in which pathways for cardiac care are based on acuity. All congenital cardiac surgical care rendered at Columbus Children's Hospital now falls within one of four such clinical pathways. This simplified approach is easy to use and has been well accepted. Our experience in a group of 107 consecutive patients treated in this fashion is described. The results of variance analyses, along with length of stay and charge data, are presented to demonstrate the degree to which resource utilization can be standardized in this widely variable group of patients whose problems were made cohesive by classification according to acuity level. We conclude that the resultant standardization offers considerable advantages for the managed care environment

571.    Huebler, D. (1995). Outcomes management. Outcomes in hand therapy... Upper Extremity Network, or UE Net, will use the collected data to identify critical pathways. Rehab Management: The Interdisciplinary Journal of Rehabilitation, 8(3), 109-111.
Abstract: Therapists are taking advantage of computer technology to research clinical outcomes and capture and document payor information

572.    Vandenbusche, P. (1995). Medication profile key to surpassing LOS reduction goal. Hospital Case Management, 3(4), 59-62.

573.    Van Buskirk, M. C., & Vanderbilt, D. (1995). Evaluating patient care by the use of a diabetic ketoacidosis CareMap in an intensive care unit setting. Journal of Nursing Care Quality, 9(3), 59-68.
Abstract: The 1990s have seen major changes in the health care delivery system. One of the more useful ones has been the CareMap, an interdisciplinary tool for managing, evaluating and improving patient care. The article discusses the use of a diabetic ketoacidosis CareMap in the medical intensive care unit in a large community hospital. The impact of the CareMap on cost containment and use of resources is also addressed. Although the CareMap represents only one of the many changes that have evolved in the past several years, it is certain to have a critical effect on patient care quality because it combines a variety of disciplines and identifies problem issues that encourage a collaborative approach to patient care

574.    Tallis, G., & Balla, J. I. (1995). Critical path analysis for the management of fractured neck of femur. Australian Journal of Public Health, 19(2), 155-9.
Abstract: The aim of this study was to determine the effect of a critical path analysis, used as a management tool, on the efficiency of clinical service delivery for patients with a fractured neck of femur. It is a before-and-after study of the medical records of all patients admitted between October 1992 and October 1993 with a primary diagnosis of fractured neck of femur, but excluding patients under 50 years old and those with multiple fractures or metastatic disease. Patients fell into two groups: those admitted in the six months before the introduction of a clinical management program based on a critical path analysis, and those admitted after the introduction of the program in April 1993 (88 program cases and 90 nonprogram cases). A medical records administrator blinded to the program category of the patients independently coded diagnostic data, while other data were abstracted from the clinical notes. The length of stay for a fractured neck of femur declined from a mean of 19.3 days to a mean of 11.0 days (P < 0.0001). The outcome measures were: the distance walked just before discharge from hospital, the discharge destination, and unplanned readmission. These did not change significantly, and the wound infection rate declined during the period of the intervention. The implementation of a clinical management pathway based on a critical path analysis dramatically reduced the length of stay for patients admitted with a fractured neck of femur while maintaining quality of outcomes. Critical path analysis is a useful management