Care Maps, Clinical Paths/Pathways, Critical Paths/Pathways 1997-98/Oct 99

     1.    Schweitzer, E. J., Wiland, A., Evans, D., Novak, M., Connerny, I., Norris, L., Colonna, J. O., Philosophe, B., Farney, A. C., Jarrell, B. E., & Bartlett, S. T. (1998). The shrinking renal replacement therapy "break-even" point. Transplantation, 66(12), 1702-8.
Abstract: BACKGROUND: This study examines the current cost of live donor (LD) transplantation at our institution, and compares it with that of dialysis. METHODS: The study population consisted of 184 consecutive adult recipients of laparoscopically procured LD kidney transplants. Cost-containment measures instituted during this series included elimination of routine postoperative antilymphocyte induction and an accelerated discharge clinical pathway with planned discharge of the recipient on postoperative day (POD) 2. Costs of the transplants to Medicare were estimated from hospital charges, readmission rates, and immunosuppressant usage. These were compared with published costs of dialysis to Medicare in terms of a fiscal transplant-dialysis break-even point. RESULTS: Kaplan-Meier patient and graft survival rates at 1 year were 97 and 93%, respectively. Among patients followed for at least 90 days and treated with no induction and either cyclosporine-mycophenolate mofetil or tacrolimus-mycophenolate mofetil, acute rejection rates were low (27.6 and 13.9%, respectively). In the last 124 patients, 32.3% were discharged by POD 3 and 71.8% by POD 6, with corresponding mean transplant hospital charges (excluding organ acquisition) of $11,873 and $17,350, respectively. The 30-day readmission rate for patients discharged on the accelerated pathway by POD 3 was only 16%. The least expensive subgroup in the present study (30% of patients) was that of patients discharged by POD 6 and not readmitted during the first year; the break-even point with dialysis costs was calculated as 1.7 years after the transplant. CONCLUSIONS: The cost of LD transplants can be safely reduced by elimination of routine postoperative anti-lymphocyte immune induction and by an early discharge clinical pathway. Uncomplicated LD kidney transplants, meaning those with a short length of stay in the hospital after transplantation and no need for readmission within the first year, accrue savings over dialysis within 2 years

     2.    Sefton, S., & Willock, M. (1998). Outcomes measurement in the operating room suite. International Anesthesiology Clinics, 36(1), 79-84.
Abstract: The objectives of quality improvement in the OR include improved perioperative care of the patient and OR efficiency, decreased hospital length of stay, and decreased costs. We submit that multidisciplinary outcome measurement is a prerequisite for coordinated outcomes management to achieve quality patient care in an effective, efficient, and financially responsible way, and we provide a guide to do so. The data obtained by such cross-discipline study can identify the need for patient, family, and/or staff education, improved interaction and collaboration across disciplines, revision of clinical paths, and improved hospital systems as well as benchmarking the performance of the OR against local or national standards

     3.    Keston, V. J., & Enthoven, A. C. (1998). Total hip replacement: a case history. [Review] [43 refs]. Health Care Management Review, 23(1), 7-17.
Abstract: The history of total hip replacement in the U.S. demonstrates that health care providers can reduce costs while improving quality. Nationwide, the cost of total hip replacements has declined dramatically while quality has improved. This article describes 14 clinical and management innovations ranging from patient education to competitive bidding. [References: 43]

     4.    Ham, J., & Jamieson, B. (1998). Critical pathways in the rehabilitation setting. Jarna, 1(2), 22-5.

     5.    Beitel, J. (1998). Positioning and intracranial hypertension: implications of the new critical pathway for nursing practice. [Review] [18 refs]. CACCN, 9(4), 12-6; quiz 17-8.
Abstract: Evidence based practice in nursing requires careful scrutiny of research studies to determine if there is support to continue existing protocols or if a change in clinical practice is warranted. Current nursing practice in critical care includes the routine elevation of the head of the bed (HOB) to 30 degrees or 45 degrees for patients with cerebral edema. Intracranial hypertension is a common complication of cerebral edema. New guidelines for medical management of intracranial hypertension have been developed and presented in a critical pathway. Positioning of patients with intracranial hypertension must be re-evaluated in light of the changing goals of medical management outlined in the critical pathway. The author of this article will critically appraise the research examining the impact of elevating the HOB on patients with intracranial hypertension within the context of the critical pathway parameters. Recommendations for positioning, in keeping with the new critical pathway for intracranial hypertension, will be suggested. Future research directions will be identified. [References: 18]

     6.    Seale, G. S., & Abreu, B. C. (1998-1999). Pathways to better care. Rehab Management, 12(1), 56-9.

     7.    Umiker, W. (1998). Medical outcomes assessment and management with emphasis on laboratory applications. Health Care Supervisor, 17(2), 55-62.
Abstract: Outcomes assessment and management are playing an increasing role in reducing costs and providing better customer satisfaction. In this overview we describe some outcomes applications and techniques, including benchmarking and clinical pathways. Some outcomes undertakings are complicated and may be frustrating, but most are rewarding to patients or health care providers or both. Challenges are discussed and laboratory applications featured.  (Abstract by: Author)

     8.    Rutkowski, K. C., & Easterling, A. D. (1998). Fast-tracking clinical pathway redesign. Part I: The redesign process. Hospital Case Management, 6(12), 235-8.

     9.    Rowen, L., Raymond, R., & Thomas, K. (1998). The patient care delivery mode at Mercy Medical Center: a licensed caregiver model. Aspens Advisor for Nurse Executives, 14(3), 1, 3-6.

   10.    Rosenberg, A. D. (1998). Ensuring early discharge following major surgery: orthopedic surgery. Journal of Cardiothoracic & Vascular Anesthesia, 12(6 Suppl 2), 7-10; discussion 41-4.
Abstract: Managed care, critical pathways, and length of stay issues have a major impact on current hospital policy and patient care. In orthopedic surgery, significant strides have been made in improving efficiency, decreasing costs, and reducing length of stay. Use of vertical pathways, especially the first day of admission, the day of surgery, is important for efficient patient care. As anesthesiologists involved in the process, we must be certain that patient care is not compromised in an attempt to save money or achieve early discharge. In many studies, pain management, type of anesthesia, and amount of blood loss are not significant factors in length of hospital stay. These factors must be approached as quality-of-life issues and appropriate decisions made

   11.    Page, C. (1998). Pathway leadership: a mature framework for teams. Seminars for Nurse Managers, 6(4), 195-8.
Abstract: Shared Governance has been a successful organizational design for Central Baptist Hospital. We are addressing critical issues that impact our success, with involvement and facilitation of the employees who make up the organization. It will continue to change as our environment and system evolve. The movement from a traditional organizational structure and culture to one of embracing shared decision making gives leaders today an additional stressor. It is difficult to critically analyze your organization when you are faced daily with the external pressures of health care competition and the internal daily pressures of operations. It takes extra effort and introspection to recognize that you and your management team must undertake new and different behaviors to lead your organization into the next millennium. One thing is clear: If you do not create an environment that is flexible and able to accommodate change, your competitor will:

   12.    Mauerhan, D. R., Mokris, J. G., Ly, A., & Kiebzak, G. M. (1998). Relationship between length of stay and manipulation rate after total knee arthroplasty. Journal of Arthroplasty, 13(8), 896-900.
Abstract: We hypothesized that a pattern of decreasing postoperative length of stay (LOS) in the hospital could lead to an increased rate of manipulation after total knee arthroplasty (TKA). The decision to manipulate is based on the patient's ability to perform normal physical activities, which may in large part be dependent on adequate knee flexion (ie, range of motion [ROM]). Decreased exposure to physical therapy (as a result of decreased LOS) may be a contributing factor leading to impaired functional ROM in the 6-week postoperative period. We examined records from 745 patients (2 surgeons) who had a primary TKA from 1993 to 1996. At our institution, development and implementation of clinical pathways resulted in a significant decrease in the average LOS beginning in 1993. The average LOS in 1993 was 6.4 +/- 1.8 days (mean +/- SD) and progressively decreased to 4.4 +/- 1.0 days in 1996 (P < .0001). The rate of manipulation (patients manipulated at 6 weeks/total number of patients receiving TKA) was 6.0% in 1993 and increased to 11.3% (P = .09) in 1994, 13.5% (P = .02) in 1995, and 12.0% (P = .05) in 1996. In the period 1993-1996, patients requiring manipulation consistently had a lower ROM at discharge from the hospital (69.0 +/- 10 degrees, n = 67, P < .0001) compared with patients not requiring manipulation (80.7 +/- 10.6 degrees, n = 542). The relatively low frequency and charge for manipulation may justify the decision to decrease patient exposure to physical therapy through reduction in LOS. As efforts to decrease LOS continue, however, we must aggressively manage patients and provide adequate exposure to inpatient and outpatient physical therapy to ensure optimal ROM results

   13.    Lykins, T., Peck, M., Poole, R., & Fisher, A. A. (1998). NCP forum. Using clinical pathways in nutrition support patient care. Nutrition in Clinical Practice, 13(6), 298-309.

   14.    Lipp, A. (1998). Clinical effectiveness: practical solutions for the new agenda. British Journal of Theatre Nursing, 8(9), 32-4.

   15.    Layton, A., Moss, F., & Morgan, G. (1998). Mapping out the patient's journey: experiences of developing pathways of care. Quality in Health Care, 7(Suppl), S30-S36.

   16.    Hill, M. (1998). Clinical excerpts... The development of care management systems to achieve clinical integration. Topics in Clinical Chiropractic, 5(4), 14-9.
Abstract: With development of managed care markets, healthcare delivery systems face increasing clinical and financial risk. For an integrated delivery system to survive, strategies for clinical integration and care management are essential. CareMap tools, collaborative practice groups, and case management serve as the foundation to accomplish care management over the health continuum. Coordination of care, within an institution and across traditional health settings, to achieve the best clinical and cost outcomes is the goal. The article discusses strategies for clinical integration, categories for measurement of performance, and the need to incorporate automated solutions into the strategic business plan. Copyright (c) 1998 by Aspen Publishers, Inc.  (6 ref)

   17.    Henning, J. M. (1998). The role of clinical practice guidelines in disease management. American Journal of Managed Care, 4(12), 1715-22; quiz 1723-4.
Abstract: This activity is designed for medical directors, pharmacy directors, quality assurance managers, and all members of disease management or quality improvement teams. GOAL: To review the guideline literature and help healthcare organizations plan guideline development and implementation strategies. OBJECTIVES: 1. Clarify the terminology used in practice policy development. 2. Explain how guideline implementation is related to disease management. 3. Discuss interventions utilized to enhance guideline adoption. 4. Provide a stepwise plan for healthcare organizations to follow.  (Abstract by: Author)

   18.    Henneman, E. (1998). From the UCLA Medical Center: a clinical pathway for gastrointestinal bleeding. Cost & Quality Quarterly Journal, 4(4), 26-31.

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

   20.    Ellis, D. G. (1998). Pathways to effective integrated pre-hospital care... trying to determine whether paramedics are effective. Journal of Clinical Effectiveness, 3(4), 166-9.
Abstract: The traditional principles of the ambulance service have served to underpin developments in pre-hospital care, which together with increasing skills of paramedics and technology have both raised the profile of the service and arguably contributed to improvements in patient care. However despite these advances patients are still transferred to hospital following treatments from paramedic responses to '999' emergencies. Evidence from the on-scene treatment of diabetics suggests that certain patient groups can be appropriately managed in the community without recourse to either secondary or primary care through increasing paramedic judgement skills. Although this alone may not be enough to encourage support from health care professionals, the development of pre-hospital care pathways with strict clinical and non-clinical criteria may provide the answer. Increasing demands on all disciplines of the health service are to some extent determining the pace at which professionals work in finding solutions to more clinically effective care. The following paper offers a hypothesis that could potentially integrate paramedics more fully into the health care system.  (14 ref)

   21.    Ekland, M., Griffin, S., Copeland, J., Elliott, S., & Nigro, M. (1998). Exploring male fertility options after spinal cord injury: the role of the nurse clinician. [Review] [7 refs]. Sci Nursing, 15(4), 95-8.
Abstract: Male sexual function and fertility are important areas that need to be addressed for men undergoing spinal cord injury (SCI) rehabilitation. Rehabilitation nurses need to understand what fertility after SCI involves. Significant advances in the areas of sperm retrieval and advanced reproductive technologies have made biological parenthood for many men with SCI a viable option. This article reviews the various sperm retrieval techniques and advanced reproductive technologies available today. It also describes the unique role of a nurse clinician working in a fertility clinic designed specifically to address the fertility concerns of men and their partners after SCI. [References: 7]

   22.    Egger, E. (1998). The home care crisis: time to abandon ship? Health Care Strategic Management, 16(12), 1-20-3.

   23.    DeLong, J. F., Allman, R. M., Sherrill, R. G., & Schiesz, N. (1998). A congestive heart failure project with measured improvements in care. Evaluation & the Health Professions, 21(4), 472-86.
Abstract: This project was designed to improve the in-hospital management of Medicare beneficiaries with congestive heart failure (CHF). Eleven hospitals were studied using two indicators: (a) assessment of left ventricular (LV) function, and (b) use of angiotensin converting enzyme (ACE) inhibitors in patients with systolic dysfunction. Baseline performance rates were obtained for 990 cases with the Diagnosis Related Group (DRG) 127 for CHF discharged January 1994 to December 1994. Baseline data feedback presentations in 1995 spurred quality improvement plans with interventions such as physician education, critical care maps, and standing orders. Follow-up abstractions were performed on 612 discharges October 1995 through April 1997. The study demonstrated 12% improvement (53% to 65%, p < .01) in assessing LV function and 20% improvement (54% to 74%, p < .01) in appropriate ACE inhibitor use. Projects emphasizing Health Care Quality Improvement Program (HCQIP) principles can successfully affect health care management for the Medicare population.  (Abstract by: Author)

   24.    Cheng, D. C. (1998). Impact of early tracheal extubation on hospital discharge. [Review] [60 refs]. Journal of Cardiothoracic & Vascular Anesthesia, 12(6 Suppl 2), 35-40; discussion 41-4.
Abstract: Economic realities of the continuing increased utilization of cardiac surgery in the 1990s have led to the practice of early tracheal extubation and shortening of the length of intensive care unit and hospital stays. In this era of cost-containment and physician report cards, we are held accountable for patients' outcome in terms of mortality, morbidity, quality of life, length of stay, and cost of care. This report outlines the factors that influence costs of cardiac surgery. These include patient risk, anesthesia, surgical, intensive care unit, and health care systems or hospital factors. The current literature on outcome, utilization, and cost implications of early tracheal extubation in cardiac surgery is summarized and discussed. It has been demonstrated that early extubation anesthesia is safe and cost-effective and can improve resource utilization in cardiac surgery, but to achieve a maximum cost benefit from fast-track or early extubation anesthesia in cardiac patients, team organization of a fast-track cardiac surgery program must be implemented. A perioperative clinical pathway management in fast-track cardiac surgery is presented. [References: 60]

   25.    Card, S. J., Herrling, P. J., Matthews, J. L., Rossi, M. L., Spencer, E. S., & Lagoe, R. (1998). Impact of clinical pathways for total hip replacement: a community-based analysis. Journal of Nursing Care Quality, 13(2), 67-76.
Abstract: The implementation of clinical pathways for total hip replacement was carried out by five hospitals in the metropolitan area of Syracuse, New York. This process occurred under the leadership of clinical nurse specialists and nurse managers. It was supported by preadmission patient education programs and active physician involvement. The participating hospitals shared utilization quality assurance data and benchmarked with respect to the experience of Sacramento, California, and each others' progress. The effort produced substantial reductions in hospital stays without adverse impacts on quality of care

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

   27.    Wadey, G., Robb, E., & Heath, F. (1998). Quality improvement. Acting with assurance. Health Service Journal, 108(5631), 30.

   28.    Paone, G., Higgins, R. S., Havstad, S. L., & Silverman, N. A. (1998). Does age limit the effectiveness of clinical pathways after coronary artery bypass graft surgery? Circulation, 98(19 Suppl), II41-5.
Abstract: BACKGROUND: Clinical pathways have been shown to be effective in reducing the length of hospital stay after isolated CABG. Few studies, however, have focused specifically on the outcomes of the pathways in regard to the elderly population. METHODS AND RESULTS: We reviewed our experience with 445 consecutive patients (299 < 70 years old [mean age, 58.2 +/- 0.5 years] and 146 > or = 70 years old [mean age, 75.6 +/- 0.3 years]) who underwent isolated CABG with the expectation of progressing through the same 5-day postoperative pathway. Preoperatively, the elderly had a smaller body surface area (1.87 +/- 0.02 versus 2.00 +/- 0.01; P < 0.001) and a higher incidence of female gender (45.9% versus 26.8%; P = 0.001), cerebrovascular disease (13.7% versus 7.0%; P = 0.022), congestive heart failure (22.6% versus 13.4%; P = 0.013), and 3-vessel coronary artery disease (76.7% versus 65.9%; P = 0.024). Postoperatively, the elderly had a higher incidence of red blood cell transfusion (28.8% versus 9.0%; P = 0.001), atrial fibrillation (37.6% versus 11.7%; P = 0.001), and overall rate of complications (46.6% versus 23.4%; P = 0.001). Mortality rate and length of stay were 5.5% and 7.9 +/- 0.4 days for the elderly versus 1.0% and 6.4 +/- 0.4 days for those < 70 years old (P = 0.004 and P = 0.008), respectively. Of those > or = 70 years old, 34% were discharged in < or = 5 days, 64% in < or = 7 days, and 82% in < or = 10 days versus 64%, 85%, and 93%, respectively, for younger patients (P = 0.001 for all). Multivariate analysis of preoperative variables identified age (P < 0.001), female gender (P < 0.001), hypertension (P = 0.017), chronic obstructive pulmonary disease (P = 0.002), preoperative intra-aortic balloon pumping (P = 0.002), and body surface area (P = 0.003) as significantly related to length of stay. However, when the postoperative variables found to be different by univariate analysis are added to the model, age is only marginally significant (P = 0.079), and red blood cell transfusion and atrial fibrillation are the strongest predictors of increased length of stay, along with intra-aortic balloon pumping and pneumonia (P < 0.001 for all). CONCLUSIONS: These data suggest that extraordinary modifications of clinical pathways are not needed for success with elderly patients. The increased length of stay is largely attributable to the increased incidence of atrial fibrillation

   29.    Theis, L. M. (1998). Cost containment and quality: coexisting in total joint care. [Review] [23 refs]. Orthopaedic Nursing, 17(6), 70-7.
Abstract: National competitive and regulatory pressures are dramatically changing health care. Total joint care programs must redesign to meet these challenges. Multidisciplinary teams must review and refine care across the total joint care continuum, which covers preop through rehab. The six key areas of care on the continuum are preop teaching/testing, implants, care paths, special equipment, discharge and rehab, and documentation/coding. Each of these areas presents opportunities to develop strategies for enhanced efficiencies across the total joint care continuum. The goal is to maintain or improve quality of care while being cost effective. [References: 23]

   30.    Slayton, J. M. (1998). Treatment algorithms: bane or boon to mental health? Harvard Review of Psychiatry, 6(4), 225-7.

   31.    Roberts, K. A. (1998). Best practices in the development of clinical practice guidelines. Journal for Healthcare Quality: Promoting Excellence in Healthcare, 20(6), 16-20, 32.

   32.    Powell, E. T., & Austin, A. (1998). Developing a pediatric diabetes critical pathway. Pediatric Nursing, 24(6), 558-61.

   33.    Meehan, A. J., Carey, N., & Haynes, D. E. (1998). A clinical pathway for the secondary diagnosis of alcohol misuse: implications for the orthopaedic patient. Orthopaedic Nursing, 17(6), 49-54, 64.
Abstract: This article presents the process of developing a method of routine identification, assessment, intervention, and follow-up for the trauma patient with a concomitant diagnosis of alcohol misuse. A clinical pathway approach to addressing the needs of the alcohol misuser is outlined, and an alternative method that adapts this approach to other settings is also presented. Ever mindful of decreasing lengths of stay and reimbursement predicated on diagnosis-related groups, this pathway is tailored to overlay onto an existing clinical path of care so as not to increase length of stay nor duplicate services

   34.    Lowry, L. M., Hays, B. J., Lopez, P., & Hernandez, G. (1998). Care paths: a new approach to high-risk maternal-child home visitation. MCN, American Journal of Maternal Child Nursing, 23(6), 322-8.
Abstract: Care paths for the maternal and infant populations are used to define immediate and long-term outcomes related to care received in the home. This article describes a care path developed by public health nurses for intervention with an at-risk maternal-child population in a city/county health department. A public health nursing care management model provided the framework for developing this care path to foster cost-effective use of limited resources. It is crucial that public health nurses articulate clearly the services provided in the home both for those who may seek service and for policy makers who determine funding structure. The project demonstrated that care paths for home visitation involving high-risk prenatal clients are useful tools that streamline documentation, foster consistency and continuity of care, facilitate quality improvement efforts, and provide outcome data.  (21 ref)

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

   36.    Cabello, C. C., & Tahan, H. A. (1998). Protocols in practice. Implementation of an interdisciplinary clinical pathway for patients after a liver transplant. Nursing Case Management, 3(6), 255-65.

   37.    Cabello, C. C., & Tahan, H. A. (1998). Implementation of an interdisciplinary clinical pathway for patients after a liver transplant. Nursing Case Management, 3(6), 255-65.

   38.    Williams, B. A., DeRiso, B. M., Figallo, C. M., Anders, J. W., Engel, L. B., Sproul, K. A., Ilkin, H., Harner, C. D., Fu, F. H., Nagarajan, N. J., Evans, J. H. 3rd, & Watkins, W. D. (1998). Benchmarking the perioperative process: III. Effects of regional anesthesia clinical pathway techniques on process efficiency and recovery profiles in ambulatory orthopedic surgery. Journal of Clinical Anesthesia, 10(7), 570-8.
Abstract: STUDY OBJECTIVES: (1) To incorporate regional anesthesia options for common outpatient orthopedic surgery into clinical pathways; (2) to use the clinical pathway format and the Procedural Times Glossary published by the Association of Anesthesia Clinical Directors (AACD) as management tools to measure postoperative same-day surgery processes and discharge outcomes; and (3) to determine the effects of general, regional, and combined general-regional anesthesia on these processes and outcomes. DESIGN: Hospital database and patient chart review of consecutive patients undergoing anterior cruciate ligament reconstruction (ACLR) during academic years (AY) 1995-1996 and 1996-1997. Patient data from AY 1995-1996, during which no intraoperative anesthesia clinical pathway existed, served as historical controls. Data from AY 1996-1997, during which intraoperative anesthesia clinical pathways were used, served as the treatment group. SETTING: Ambulatory surgery center in a teaching hospital. MEASUREMENTS AND MAIN RESULTS: The records of 503 ASA physical status I and II patients were reviewed. 1996-1997 patients selected general anesthesia (+/- femoral nerve block) or epidural anesthesia, after which the remainder of the perioperative anesthesia process was standardized with respect to the drugs and equipment used. 1995-1996 patients did not necessarily have a choice in anesthesia technique and did not have a standardized perioperative anesthetic course with respect to specific drugs and supplies. Intervals described in the AACD Procedural Times Glossary, anesthesia drug and supply costs, and patient outcome variables (postoperative nursing interventions required and unexpected admissions), as influenced by anesthesia technique used, were measured. Combined general-regional anesthesia care for ACLR in 1996-1997, when compared with general anesthesia alone, led to increased pharmacy and materials costs and increased turnover time. However, patients with the combined technique showed improved recovery profiles and lower unexpected admission rates, and they required fewer nursing interventions for common postoperative symptoms. Patients receiving epidural anesthesia showed discharge outcomes similar to those patients receiving general anesthesia with femoral nerve block. Postanesthesia care unit bypass (fast-tracking) was more likely in clinical pathway regional anesthesia patients, when compared with the clinical pathway general anesthesia used. CONCLUSIONS: Clinical pathway regional anesthesia care for outpatient orthopedics may have a significant role in simultaneously containing costs and improving both process efficiency and patient outcomes

   39.    Williams, B. A., DeRiso, B. M., Engel, L. B., Figallo, C. M., Anders, J. W., Sproul, K. A., Ilkin, H., Harner, C. D., Fu, F. H., Nagarajan, N. J., Evans, J. H. 3rd, & Watkins, W. D. (1998). Benchmarking the perioperative process: II. Introducing anesthesia clinical pathways to improve processes and outcomes and to reduce nursing labor intensity in ambulatory orthopedic surgery. Journal of Clinical Anesthesia, 10(7), 561-9.
Abstract: STUDY OBJECTIVES: (1) To introduce anesthesia clinical pathways as a management tool to improve the quality of care; (2) to use the Procedural Times Glossary published by the Association of Anesthesia Clinical Directors (AACD) as a template for data collection and analysis; and (3) to determine the effects of anesthesia clinical pathways on surgical processes, outcomes, and costs in common ambulatory orthopedic surgery. DESIGN: Hospital database and patient chart review of consecutive patients undergoing anterior cruciate ligament reconstruction (ACLR) during academic years (AY) 1995-1996 and 1996-1997. Patient data from AY 1995-1996, during which no intraoperative anesthesia clinical pathways existed, served as historical controls. Data from AY 1996-1997, during which intraoperative anesthesia clinical pathways were used, served as the treatment group. Regional anesthesia options were routinely offered to patients in the clinical pathway. SETTING: Ambulatory surgery center in a teaching hospital. MEASUREMENTS AND MAIN RESULTS: The records of 503 ASA physical status I and II patients were reviewed. 1996-1997 patients underwent clinical pathway anesthesia care in which the intraoperative and postoperative anesthesia process was standardized with respect to symptom management, drugs, and equipment used. 1995-1996 patients did not have a standardized intraoperative and postoperative anesthetic course with respect to the management of common symptoms or to specific drugs and supplies used. Intervals described in the AACD Procedural Times Glossary, anesthesia drug and supply costs, and patient outcome variables (postoperative nursing interventions required and unexpected admissions), as influenced by the use of the anesthesia clinical pathway, were measured. Clinical pathway anesthesia care of ACLR in 1996-1997, which actively incorporated regional anesthesia options, reduced pharmacy and materials cost variability; slightly increased turnover time; improved intraoperative anesthesia and surgical efficiency, recovery times, and unexpected admission rates; and decreased the number of required nursing interventions for common postoperative symptoms. CONCLUSIONS: Clinical pathway patient management systems in anesthesia care are likely to produce useful outcome data of current practice patterns when compared with historical controls. This management tool may be useful in simultaneously containing costs and improving process efficiency and patient outcomes

   40.    Tovar, E. A. (1998). Minimally invasive approach for pneumonectomy culminating in an outpatient procedure [see comments]. Chest, 114(5), 1454-8.
Notes: Comment in: Chest 1999 Jun;115(6):1753-5
Abstract: STUDY OBJECTIVE: To establish the effects of the use of a clinical pathway that includes a minimally invasive access among patients undergoing pneumonectomy. DESIGN: Prospective study from February to December of 1997. SETTING: A community hospital. PATIENTS: Five consecutive patients with a mean age of 60 years (range 43 to 74 years) with lung malignancies who required pneumonectomy. INTERVENTIONS: Clinical pathway based on patient education, a meticulous minimally invasive operation (oblique muscle-sparing minithoracotomy), intercostal nerve cryoanalgesia, and a quick postoperative resumption of physical activity. RESULTS: All five patients were extubated in the operating room. They all had unrestricted shoulder mobility in the recovery room, and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation, and one patient was able to ambulate freely only a few hours after the procedure. Four patients were discharged the day after surgery, and one patient was discharged the same day of the operation. None required readmission related to the procedure. CONCLUSION: This initial experience seems to indicate that the application of this clinical pathway in patients undergoing pneumonectomy greatly accelerates their recovery and, for a select group of patients, converts it into an outpatient procedure

   41.    Spath, P. L. (1998). Avoiding pitfalls of clinical pathways. Or-Manager, 14(11), 13-4.

   42.    Quintaliani, G., & Cencetti, S. (1998). Quality and accreditation in nephrology. The Italian perspective. Management and quality control. International Journal of Artificial Organs, 21(11), 762-6.
Abstract: The economic approach of the industrial and commercial sector cannot be transferred to the medical one without proper measures. The final objective of the health service is not to gain profits but rather to achieve results in terms of health. Professional quality and, therefore, appropriateness becomes the foundation for proper management. In turn, appropriateness means to do the right things when they are useful regarding both the organisational, administrative, educational and training aspects and the medical ones. Management control is the right answer to this challenge to know and monitor consumption, strategies and results in relation to preestablished administration health policy objectives. Its purpose is to allow the organisation to carry out its objectives with the highest effectiveness and efficiency possible and it is joined with technical-professional elements which orient and support management in a logic of total quality. The adoption of the process of management control does not mean to turn doctors into managers. It must be hoped that doctors will understand the economic implications of the decisions made at clinical level as well as the technical-organisational ones. A medical action becomes effective if it is part of a system in which each person involved carries out his duties in an integrated logic where relationships are clearly defined. To decide what is appropriate, one refers to what is known and proven. It is clear that the problem of quality must be faced firmly and systematically. The activation of a quality program is not only based on the definition of "good practice", in terms of procedures, protocols, pathways and reference parameters for measuring quality but rather on the introduction of clinical methods that can guarantee a series of highly important opportunities

   43.    Nemeth, L., Hendricks, H., Salaway, T., & Garcia, C. (1998). Integrating the patient's perspective: patient pathway development across the enterprise. Topics in Health Information Management, 19(2), 79-87.
Abstract: Two academic medical centers in a newly integrated structure joined to understand better their patients' experience with care processes and to promote increased patient involvement in the plan of care. Through a team approach, a patient pathway was developed using graphic and text elements to illustrate the normal sequence of critical activities and care processes for established clinical pathways at these medical centers. A focus group was held to achieve a higher level of patient input into care coordination issues. Through the integration of the patient's voice into the plan of care, priorities for improvement can be identified.  (Abstract by: Author)

   44.    Mass, S., & Johnson, B. (1998). Case management and clinical guidelines. Journal of Care Management, (Spec Ed), 18-26.

   45.    Luttman, R. J. (1998). Next generation quality, Part 2: Balanced scorecards and organizational improvement. Topics in Health Information Management, 19(2), 22-9.
Abstract: Part 1 of this two-part series defined a new quality paradigm called the next generation quality model. This model applies the principles of the Malcolm Baldrige Criteria for Performance Excellence to clinical processes. The model's components are clinical pathways, variance management systems, stream-lined patient documentation, and continuous improvement. Part 2 extends the next generation quality model, describes the principles and applications of integrated performance measurement systems, and explains how measurement systems are adapted to different levels of an organization to effect change.  (Abstract by: Author)

   46.    Luttman, R. J. (1998). Next generation quality, Part 1: Gateway to clinical process excellence. Topics in Health Information Management, 19(2), 12-21.
Abstract: The quality movement has gone through three phases in this century. The first, quality assurance, emphasized reacting to problems and identifying "bad apples." The second, quality improvement, shifted the focus from individuals to processes but still retained a reactive problem-solving approach to improving the quality of products and services. The third phase, quality management, has gained strength in other industries over the years. The article presents a quality management, or "next generation quality," model for health care centered on clinical pathways as core clinical processes that are continuously improved and monitored through an improved version of variance management systems called the gateway model.  (Abstract by: Author)

   47.    Kazmirski, G. (1998). Marketing quality and value to the managed care market. Topics in Health Information Management, 19(2), 62-9.
Abstract: Quantifying quality and marketing care delivery have been long-term challenges in the health care market. Insurers, employers, other purchasers of care, and providers face a constant challenge in positioning their organizations in a proactive, competitive niche. Tools that measure patient's self-reported perception of health care needs and expectations have increased the ability to quantify quality of care delivery. When integrated with case management and disease management strategies, outcomes reporting and variance analysis tracking can be packaged to position a provider in a competitive niche.  (Abstract by: Author)

   48.    Glassman, K. S., & Kelly, J. (1998). Facilitating care management through computerized clinical pathways. Topics in Health Information Management, 19(2), 70-8.
Abstract: The development and implementation of clinical pathways at New York University Medical Center and the transition to a computerized multidisciplinary documentation system took place between 1995 and 1998. Both the computerized system and the pathway program evolved simultaneously over this 3-year period. The article describes the process of creating the clinical pathways and the automated documentation system to support the clinical pathways. Migration from the paper pathway to the automated system required the efforts of an interdisciplinary team, which focused on issues such as translation of written pathway detail into language that could be loaded into the automated system. The advantages, pitfalls, and lessons learned in this integration experience are also described.  (Abstract by: Author)

   49.    Dzwierzynski, W. W., Spitz, K., Hartz, A., Guse, C., & Larson, D. L. (1998). Improvement in resource utilization after development of a clinical pathway for patients with pressure ulcers. Plastic & Reconstructive Surgery, 102(6), 2006-11.
Abstract: Clinical pathways are interdisciplinary patient care plans intended to reduce variance and improve quality of care while lowering health care cost. This study was undertaken to determine whether the development of a clinical pathway for care of patients with pressure ulcers can indeed decrease health care costs while preserving quality of care. A clinical pathway for surgical reconstruction of pressure ulcers was developed by standardizing the current practices of our plastic surgeon group. The pathway provided direction in optimal scheduling of physician interventions along with nursing, physical and occupational therapies, and spinal cord rehabilitation interventions. It covered all potential elements of patient care, including laboratory, radiology, dietary services, intravenous fluids, and use of specialty beds. It defined patient outcomes and outlined discharge planning. Pathways were distributed throughout all services caring for patients with pressure ulcers. Patient charts and billing data were reviewed for the 16-month periods before and after initiation of the pathway. No other significant changes in treatment occurred during this time frame. Ninety-seven patient charts were examined (54 before pathway and 43 after pathway implementation). Parameters evaluated included length of stay and total charges (including bed use, medications, laboratory tests, and radiology). Patient readmission rate was also examined. A significant reduction in patient length of stay and total charges was achieved after implementation of the clinical pathway. Reduction was seen not only for patients treated with flaps by plastic surgery but also for patients with pressure ulcers who were not specifically targeted such as those from other services. The readmission rate decreased slightly, although not significantly, after the pathway inception. Total cost saving was almost $11,000 per patient (23 percent). In conclusion, implementation of a clinical pathway, because it standardizes care and reduces variations and duplication of care, can reduce health care cost without impairing quality of care in the treatment of decubitus ulcer patients

   50.    Dexter, F., Macario, A., & Dexter, E. U. (1998). Computer simulation of changes in nursing productivity from early tracheal extubation of coronary artery bypass graft patients. Journal of Clinical Anesthesia, 10(7), 593-8.
Abstract: STUDY OBJECTIVE: To determine whether the results from a clinical trial, which showed that early extubation of elective coronary artery bypass graft (CABG) patients can reduce hospital costs by more rapid discharge of patients from the intensive care unit (ICU), are likely to apply to other hospitals. DESIGN: Discrete-event computer simulation. MEASUREMENTS AND MAIN RESULTS: We (1) generated simulated CABG patients, (2) had them "flow" from one condition to the next according to specified rules, and (3) calculated the labor productivity of simulated nurses who would be caring for the patients. We defined nursing labor productivity as the number of patients undergoing elective CABG cared for each year per nursing full-time equivalent working 40 hours per week. Our simulations predict that the increase in nursing labor productivity achieved by early extubation of CABG patients is sensitive to the number of elective CABG cases performed each year at the hospital and the method of compensating nurses. Hospitals with an "hourly workforce" and many cases per year are predicted to achieve a greater increase in productivity from early extubation than are hospitals with a "salaried workforce" and less active volume. At hospitals with a salaried workforce, increasing the percentage of patients extubated early may have no effect on labor productivity. CONCLUSIONS: Although "fast-tracking" protocols may offer benefits other than increasing nursing labor productivity (i.e., saving money), the results of clinical trials that demonstrate cost savings from clinical pathways that include early tracheal extubation are likely to apply only to hospitals that have similar annual CABG volume and method of compensating nurses as those in the clinical trial. To estimate the likely economic impact from early extubation protocols, a hospital should complete a simulation study with parameter values appropriate to its institution

   51.    D'Amato, L. O. Jr, Talmage, L. A., Hyde, K., McKnight, S., & Vandenbusche, P. (1998). Outcomes in abdominal hysterectomy patients with benign disease. Use of physician-developed clinical protocols. Journal of Reproductive Medicine, 43(11), 975-85.
Abstract: OBJECTIVE: To develop a clinical protocol for standardizing preoperative and postoperative care in abdominal hysterectomy patients with benign disease while maintaining quality and increasing efficiency. STUDY DESIGN: Protocol and nonprotocol groups of patients were compared with respect to key quality and efficiency outcomes in a non-randomized study. Patient group outcomes were compared using descriptive, Student's t, chi 2 and log-rank statistics. Statistical tests were performed at a .05 level of significance. RESULTS: Results from two separate protocol study periods conducted in 1996 and 1997 are reported. In both study periods statistical analyses and graphic presentations illustrate that protocol implementation improved quality of care by increasing the percentage of patients receiving appropriate antibiotic prophylaxis; maintained quality as monitored through 30-day readmission rates and a postdischarge patient survey; and improved efficiency, as evidenced by shorter times to incision and length of hospital stay. CONCLUSION: At Toledo Hospital, the clinical practice protocol directed at abdominal hysterectomy patients has been an effective tool in efforts to improve quality and efficiency in patient care

   52.    Bertholf, L. (1998). Clinical pathways from conception to outcome. Topics in Health Information Management, 19(2), 30-4.
Abstract: A provider must demonstrate superior performance in several areas, such as cost, utilization, and clinical outcomes, to obtain designation as a Center of Excellence. A comprehensive orthopedic strategy was designed for use by Good Samaritan Health Systems to obtain this designation. The strategy included the development of clinical pathways and a profiling system. Acute, subacute, home care, and patient/family pathways were developed for diagnosis-related group 209: total joint replacement. Six months after implementation, a profile was developed using the Dartmouth Clinical Value Compass. Dimensions profiled included patient satisfaction, clinical variance data, functional status, and cost/utilization data. Improvements were identified in patient satisfaction, cost/utilization, and patient care.  (Abstract by: Author)

   53.    Maxwell, C. N. (1998). Casemix perspectives for clinicians in the private sector. Medical Journal of Australia, 169(Suppl ), S48-S50.
Abstract: All private hospitals and clinics must now supply deidentified data, using AN-DRG classification, on all admitted patients to the Private Hospitals Data Bureau. Contracts between health funds and hospitals must also be described on the basis of AN-DRGs, which will enable funds to undertake hospital variance analysis. These data provide the foundation for nationally developed clinical pathways and utilisation reviews which could modify clinical practice, improve standards and reduce health costs. Clinicians must understand and participate in these changes, and adequate safeguards are needed to protect them against loss of their clinical integrity, and against inappropriate discretionary control by private hospitals, healthcare corporations and health insurers

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

   55.    Earnest, M. P., Grimm, S. M., Malmgren, M. A., Martin, B. A., Meehan, M., Potter, M. B., Steele, A. W., & Zocholl, J. R. (1998). Quality improvement in an integrated urban healthcare system: a necessary journey. Clinical Performance & Quality Health Care, 6(4), 193-200.
Abstract: Public hospitals and clinics in the United States provide health care for the needs of large numbers of people who are medically indigent, homeless, chronically mentally ill, and suffer medical and social disorders associated with poverty. These "safety-net" healthcare providers traditionally struggle with barriers to providing high-quality, patient-sensitive care, including decaying physical facilities, burdensome bureaucracies, underfunded capital equipment and construction programs, and complex, politically driven budgets and governance. However, these same institutions now must compete for their own Medicaid and Medicare clientele because the private sector is marketing to those patients. They also must continue to provide increasing services to growing numbers of uninsured patients. To accomplish this, these institutions must reinvent themselves as patient-focused, high-quality, cost-effective healthcare providers. The Denver Health system is the public safety-net provider for the city and county of Denver. This large public institution has instituted a multifaceted performance-improvement program. The program includes training employees for patient-focused service, implementing continuous quality-improvement practices, instituting clinical pathways, revising the preexisting ambulatory quality-management program, reengineering key aspects of ambulatory clinic services, and redesigning the hospital-based patient-care services. Major successes have been achieved in some initiatives, but not in all. Many key "lessons learned" may guide others.  (Abstract by: Author)

   56.    Wisser, S. H. (1998). Ethicolegal perspectives. Chart documentation: far reaching concerns. Journal of Neuroscience Nursing, 30(5), 326-329.

   57.    Summers, D., & Soper, P. A. (1998). Implementation and evaluation of stroke clinical pathways and the impact on cost of stroke care. Journal of Cardiovascular Nursing, 13(1), 69-87.
Abstract: Saint Luke's Hospital is a 642-bed urban, tertiary, teaching hospital in metropolitan Kansas City, Missouri. In 1992, Saint Luke's developed a "Collaborative Care" program supported by tools such as clinical paths as a means to assure quality stroke care and to continually improve outcomes. This article describes the development of a comprehensive Collaborative Care Program for stroke patients, highlights the development of a dedicated stroke unit, and stroke clinical path, and describes the clinical and fiscal outcomes from these efforts

   58.    Smith-Rooker, J. L., & Hodges, L. C. (1998). Managing patients with carotid stenosis. [Review] [20 refs]. MEDSURG Nursing, 7(5), 280-1, 284-292.
Abstract: Patients with carotid stenosis present multiple challenges to the medical-surgical nurse case manager. Implementing a defined critical pathway for the patient undergoing a carotid endarterectomy can result in quality cost-effective care, fewer complications, and less possibility of future stroke. [References: 20]

   59.    Shandera, K. C., Thibault, G. P., & Deshon, G. E. Jr. (1998). Efficacy of one dose fluoroquinolone before prostate biopsy. Urology, 52(4), 641-3.
Abstract: OBJECTIVES: To demonstrate the efficacy of a simple preparation for prostate biopsy (PBX) and to determine its potential cost savings. METHODS: One hundred fifty consecutive PBXs were performed using a Fleet enema and a single oral dose (300 mg) of ofloxacin as the pre-PBX preparation. RESULTS: Of the 150 PBXs we performed, only 1 (0.67%) patient developed a urinary tract infection. CONCLUSIONS: A simple and inexpensive pre-PBX preparation proved to be successful in preventing infectious complications and is presented as a potential model for inclusion in clinical pathways for diagnosing adenocarcinoma of the prostate

   60.    Rouse, A. D., Tripp, B. L., Shipley, S., Pories, W., Cunningham, P., & MacDonald, K. J. (1998). Meeting the challenge of managed care through clinical pathways for bariatric surgery. Obesity Surgery, 8(5), 530-4.
Abstract: BACKGROUND: The 1990s will bring sweeping changes in managed care and capitation. Health care providers are continually searching for new ways to improve the quality of patient-care outcomes in the obese. Improving clinical care by promoting the use of processes that have been proved to yield optimal outcomes has become a powerful strategy for measuring the value of services provided. METHODS: To address this cost/quality paradox, an optimal care path (OCP) was developed as a guideline for all patients undergoing gastric bypass or laparoscopic adjustable gastric banding. A transdisciplinary team developed the OCP, preprinted orders, discharge home instruction sheet, and daily guidelines for patients. All patients were provided with OCPs from July 1995 to September 1997. RESULTS: Length of stay decreased from 6.5 days to 5.4 days (16.9%); the average total charges decreased 17.6%, or $2,683; the percentage of wound infections decreased; and communication between, and collaboration of, interdisciplinary team members increased across the continuum of care. CONCLUSIONS: The study suggests that the use of OCP does not impair quality of care and can produce significant cost savings to a health care facility

   61.    Ross, S., Togger, D., & Desjardins, D. (1998). Asthma disease management program cuts readmissions. Hospital Case Management, 6(10), 197-200.

   62.    Nunez, G., & del Peso, L. (1998). Linking extracellular survival signals and the apoptotic machinery. [Review] [59 refs]. Current Opinion in Neurobiology, 8(5), 613-8.
Abstract: The survival of cells in multicellular organisms requires continuous stimulation from the extracellular environment. The phosphatidylinositol-3' kinase/Akt signaling cascade has been identified as a critical pathway for the transduction of extracellular survival signals. The finding that the pro-apoptotic protein BAD is a substrate of Akt/PKB has provided the first link between extracellular survival signals and the apoptotic machinery. [References: 59]

   63.    Homa-Lowry, J. (1998). Reviewing the data: what ORYX means to you. Hospital Case Management, 6(10), 195-6, 201-2, 207.
Abstract: The role of case managers in reviewing and analyzing outcomes data as part of the Joint Commission on Accreditation of Healthcare Organizations' ORYX initiative is often neglected. Case managers who become involved in reviewing ORYX data should first find out who the data vendor is and what methods are used for severity adjustment or risk adjustment. Information from ORYX can be used to evaluate areas of potential improvement in the case management program and identify ways to refine and add to existing clinical pathways.  (Abstract by: Author)

   64.    Guin, P., & Nalli, B. (1998). Decreasing roadblocks and improving outcomes: the spinal cord injury (SCI) clinical pathway. Sci Nursing, 15(3), 66-74.
Abstract: The spinal cord injury (SCI) population has many needs that require a variety of health care services. The coordination of care throughout the continuum from the time of injury to the return to maximum independence poses many challenges for the health care team. The goal of an SCI clinical pathway is the coordination of care to achieve optimal functional outcomes through the delivery of interdisciplinary, patient-focused, and cost-effective care. A pathway for the non-ventilator dependent tetraplegic was developed and implemented by a team of health care professionals in a vertically integrated health care system. Continuous quality improvement tools, data analysis, and benchmarking with other facilities were used to identify roadblocks to optimal care and opportunities to improve outcomes across the continuum. Four interdisciplinary subgroups identified care needs within each of four phases, i.e., prehospital, critical care, acute care, rehab/home care. Each phase was integrated into a continuum of care pathway to facilitate seamless transitions between sites of care. Because clinical pathways are evolutionary, a clinical variance tracking system was established to evaluate achievement of identified outcomes and needed practice changes. In addition, an ongoing cost-analysis system was used to determine the optimum care delivery site for each phase in the continuum.  (4 ref)

   65.    Goldstein, L. B., Hey, L. A., & Laney, R. (1998). North Carolina stroke prevention and treatment facilities survey: rtPA therapy for acute stroke. Stroke, 29(10), 2069-72.
Abstract: BACKGROUND and PURPOSE: North Carolina is situated in the "stroke belt" region of the United States, an area of the country with a particularly high incidence of cerebrovascular disease. The North Carolina Stroke Prevention and Treatment Facilities Survey was carried out to determine the availabilities of a variety of stroke prevention and treatment services throughout the state. The purpose of the present study was to determine how widely recombinant tissue-type plasminogen activator (rtPA) has been adopted for the treatment of patients with acute ischemic stroke and to determine the characteristics of the medical facilities in the state offering this therapy. METHODS: A single-page survey was mailed to the medical center directors of each inpatient medical facility in North Carolina. Data collected included questions related to the availability of selected basic and advanced diagnostic tests and procedures, stroke prevention and treatment programs and services (community stroke awareness program, acute stroke identification program, acute stroke team, stroke rtPA protocol, stroke care map, neurologist), and facilities (Stroke Acute Care Unit or equivalent). RESULTS: Responses were obtained from all 125 inpatient medical facilities in North Carolina. rtPA stroke protocols were adopted in 54 facilities located in 46 of the state's 100 counties. Seventy-four percent of the state's population resides in counties with hospitals providing rtPA treatment. Compared with facilities not offering rtPA, those with rtPA protocols more commonly sponsored stroke community awareness programs (41% versus 17%, P=0.003) and more frequently had an organized stroke team (31% versus 8%, P=0. 001), used stroke care maps (56% versus 17%, P<0.001), had rapid stroke identification programs (33% versus 6%, P<0.001), or had a Stroke Acute Care Unit or its equivalent (33% versus 7%, P<0.001). Neurologists were available in 78% of the facilities offering rtPA compared with 38% in facilities without rtPA protocols (P<0.001). CONCLUSIONS: These data show that this new therapy for ischemic stroke is potentially available to a high proportion of the state's citizens based on their county of residence. However, other services that may improve outcomes and reduce stroke-related costs (eg, stroke teams, stroke units, care maps) are not being widely used, even in centers providing treatment with rtPA. The simple methodology used in this study is potentially applicable in other states and permits targeting of selected centers for development of stroke treatment capabilities

   66.    Francis, R. J., & Batsie, C. (1998). Critical pathways: not just for patients anymore. Nursing Management, 29 (10), 46-8.
Abstract: Hospital managers initiate a nurse orientation program modeled after critical pathways. The structure allows them to assess nurses' competency while providing experience

   67.    Forsyth, T. J., Maney, L. A., Ramirez, A., Raviotta, G., Burts, J. L., & Litzenberger, D. (1998). Nursing case management in the NICU: enhanced coordination for discharge planning. Neonatal Network, 17(7), 23-34.
Abstract: A primary goal of health care today is finding alternative ways to provide high-quality, cost-effective care. A model of care that addresses these issues is nursing case management. This article describes the development and implementation of nursing case management in a Level III regional center with the primary goal of enhancing coordination for discharge planning. The model involves development of clinical pathways and utilization of nurse practitioners as case managers. Decreased length of stay, charge per case, and readmission rates are demonstrated following implementation of this program

   68.    Deaton, C. (1998). Outcomes measurement. Multidisciplinary approaches and patient outcomes after stroke. Journal of Cardiovascular Nursing, 13(1), 93-6.
Abstract: Synergism is an apt description for the powerful results that can occur when multidisciplinary approaches are used. Studies have documented that multidisciplinary teams produce improved patient outcomes in selected patient groups, including recent studies of patients with strokes. Multidisciplinary teams in patient care are still far from being the normative model of care delivery. In the interest of better patient care and outcomes, it is time for health care professionals to actively engage in multidisciplinary approaches, because the sum of our collaborative efforts is greater than our individual disciplinary parts

   69.    Collier, P. E. (1998). Changing trends in the use of preoperative carotid arteriography: the community experience. Cardiovascular Surgery, 6(5), 485-9.
Abstract: Between 1 January 1991 and 31 December 1994, 215 carotid endarterectomies were performed at the authors' institution, which utilized a clinical pathway. Prior to May 1992, arteriography was performed routinely. A near perfect correlation was found between the arteriograms and duplex scans when they were compared as part of the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) vascular laboratory accreditation process. A policy of selective arteriography was instituted in May 1992. Only 11 arteriograms were performed on the next 148 patients (7%) who underwent carotid endarterectomies. Arteriography was performed on two patients with extremely high bifurcations, and five patients when an exact degree of stenosis could not be determined. Two patients with simultaneous mid common carotid and bifurcation stenoses had arteriography to confirm the duplex findings. Arteriography confirmed a long, high-grade internal carotid artery stenosis, which was felt to be operable by duplex, and a simultaneous bifurcation and suspected left common carotid orificial stenosis in one patient each. Arteriograms were performed on three non-operated patients felt to have occluded internal carotid artery on duplex scanning. Two had string-like internal carotid arteries that extended intracranially from the bifurcation, and one patient had an internal carotid artery dissection. Duplex results were grossly confirmed at operation and pathologically. There were no neurological complications in those patients undergoing carotid endarterectomies based on the results of duplex scanning alone. Carotid endarterectomies can be safely performed based on the results of a duplex scan performed in an accredited vascular laboratory. This approach eliminates the risk and cost of arteriography. Approximately 10% of patients will require arteriography if the duplex scan is equivocal or shows disease at other areas than the carotid bifurcation

   70.    Benitz, W. E., Han, M. Y., Madan, A., & Ramachandra, P. (1998). Serial serum C-reactive protein levels in the diagnosis of neonatal infection. Pediatrics, 102(4), E41.
Abstract: OBJECTIVE: To evaluate serial serum C-reactive protein (CRP) levels for diagnosis of neonatal infection. SETTING: A regional intensive care nursery and two community intensive care nurseries. METHODS: All neonates treated for suspected bacterial infection were prospectively evaluated using a standardized clinical pathway. Infants were categorized as having proven sepsis (bacteria isolated from blood, cerebrospinal fluid, or urine culture), probable sepsis (clinical and laboratory findings consistent with bacterial infection without a positive culture), or no sepsis (findings not consistent with sepsis), without consideration of CRP levels. Infants whose blood cultures yielded skin flora but who demonstrated no other signs of bacterial infection were not considered to have sepsis. CRP levels were determined at the initial evaluation and on each of the next two mornings. Sensitivity, specificity, predictive values, and likelihood ratios were calculated for the first (CRP :1), second (CRP :2), higher of the second and third (CRP :2 and :3), or highest of all three CRP levels (CRP x 3). RESULTS: Sepsis was suspected within the first 3 days after birth in 1002 infants (early-onset) and on 184 occasions in 134 older infants (late-onset). There were 20 early-onset and 53 late-onset episodes of proven sepsis, and 74 early-onset and 12 late-onset episodes of probable sepsis. CRP :1 had sensitivities of 39.4% and 64.6% for proven or probable sepsis and 35.0% and 61.5% for proven sepsis in early-onset and late-onset episodes, respectively. CRP levels on the morning after the initial evaluation (CRP :2) had higher sensitivities (92. 9% and 85.0% for proven or probable sepsis and 78.9% and 84.4% for proven sepsis in early-onset and late-onset episodes, respectively), and normal results were associated with lower likelihoods of infection (likelihood ratios for normal results of 0.10 and 0.19 for proven or probable sepsis and 0.27 and 0.21 for proven sepsis, in early-onset and late-onset episodes, respectively). Three serial serum CRP levels had sensitivities of 97.8% and 98.1% for proven or probable sepsis and 88.9% and 97.5% for proven sepsis in early-onset and late-onset episodes, respectively. The negative predictive values for CRP x 3 were 99.7% and 98.7% for both proven or probable sepsis and for proven sepsis in early-onset and late-onset episodes, respectively. A CRP level obtained at the time of the initial evaluation can be omitted without significant loss of sensitivity or negative predictive value: the sensitivities of CRP :2 and :3 were 97.6% and 94.4% for proven or probable sepsis and 88.9% and 96.4% for proven sepsis in early-onset and late-onset episodes, respectively; negative predictive values were 99.7% both for proven and for proven or probable early-onset sepsis, 97.6% for proven or probable late-onset infection, and 98.8% for proven late-onset infection. Serial normal CRP levels were associated with a markedly reduced likelihood of infection as compared with that in the entire population before testing, with likelihood ratios ranging from 0.03 to 0.16 for the various subgroups. Maximum CRP levels >3 mg/dL had positive predictive values >20% for proven or probable early-onset infections and for proven or probable and proven late-onset infections, but only those >6 mg/dL had such a high positive predictive value for proven early-onset sepsis. CONCLUSIONS: Serial CRP levels are useful in the diagnostic evaluation of neonates with suspected infection. Two CRP levels <1 mg/dL obtained 24 hours apart, 8 to 48 hours after presentation, indicate that bacterial infection is unlikely. The sensitivity of a normal CRP at the initial evaluation is not sufficient to justify withholding antibiotic therapy. The positive predictive value of elevated CRP levels is low, especially for culture-proven early-onset infections

   71.    Roebuck, A. (1998). Critical pathways: an aid to practice. Nursing Times, 94(35), 50-1.
Abstract: The introduction of critical pathways in a invasive cardiology unit has resulted in a reduction in time spent on documentation by nursing staff, in patient complaints and an improvement in the quality of information collected, as measured by clinical audit. This paper describes the transition from the use of nursing care plans to multidisciplinary critical pathways. The positive and negative aspects of critical pathways and their implementation are explored

   72.    Montague, T., Tsuyuki, R., & Teo, K. (1998). Improving women's health quality: the value of closing the care gap. Hospital Quarterly, 2(1), 36-9.

   73.    Mandzuk, L. L. (1998). A total hip arthroplasty critical path: a step in the right direction. Orthoscope, 4(3), 13-6.

   74.    Hassaballa, H., Payne, J., McFolling, S., & Marder, R. J. (1998). Enhancing clinical pathway placement. Quality Management in Health Care, 7(1), 13-7.
Abstract: Soaring health care costs have fueled the immense growth in managed care. To contain these costs, health care organizations have turned to clinical pathways. However, clinical pathways cannot do an effective job if health care personnel are not aware of their existence. The article presents a simple, effective, and efficient method to increase placement of clinical pathways in inpatient medical records.  (Abstract by: Author)

   75.    Clarke, M. (1998). Implementation of nursing standardized languages: NANDA, NIC & NOC. On-Line Journal of Nursing Informatics, 2(2), no pagination.
Abstract: The use of nursing standardized languages in an acute care community hospital began in the mid to late 1970s. In the early years, the use of the North American Nursing Diagnosis Association (NANDA) classification was the impetus for evolutionary changes in both nursing standards and practice. With the addition of the Nursing Interventions Classification (NIC) and the Nursing Outcomes Classification (NOC), nursing standardized language use has transcended the changes occurring in health care delivery including case management, clinical pathways, and the multi disciplinary focus of patient care delivery. This article will trace these changes that have occur-red starting with the use of nursing diagnosis and the integration of other nursing classification systems in the patient plan of care, the introduction of a competency based orientation program, and the development of clinical pathways.  (5 ref)

   76.    Cardozo, L., Ahrens, S., Steinberg, J., Lepczyk, M. B., Kaplan, C., Burns, J., LaPlante, J., Wright, C., Spybrook, K., Racine, E., & Valade, T. (1998). Implementing a clinical pathway for congestive heart failure: experiences at a teaching hospital. Quality Management in Health Care, 7(1), 1-12.
Abstract: Clinical pathways are processes of care that use a multidisciplinary team effort to move patients toward a designed outcome. This article details the challenges of a Quality Enhancement and Clinical Resource Management Team in designing and implementing a successful congestive heart failure pathway at a teaching hospital. Academic institutions have the resources as part of their research mission, to enhance the development of clinical pathways and assess their outcomes.  (Abstract by: Author)

   77.    Zander, K. (1998). Clinical pathways. Where will clinical paths lead home care? Remington Report, (Spec Issue), 7-8.

   78.    Rosenberg, M. L. (1998). Developing behavioral health clinical guidelines for depression: emerging standards for guiding care. Nursing Case Management, 3(5), 204-7.

   79.    Leyden, C. G., & Abbott, C. (1998). Continuum of care. Traumatic brain injury care path. Pediatric Nursing, 24(5), 470-473.

   80.    Leininger, S. M., & Cohen, P. Z. (1998). The quality circle of hip fracture care. Nursing Case Management, 3(5), 220-6.
Abstract: Elderly patients with hip fractures have many medical, physical, and psychosocial challenges. Their care can become complex and require the integration of various disciplines. In this article, the author describes and explains the hip fracture preoperative assessment tool that contains various "red flag" indicators and tools used for data collection. The case manager can use this tool to assess patients before surgery and appropriately plan for discharge. Outcome results are discussed, including functional status, length of stay, and costs

   81.    Leininger, S. (1998). Quality circle of joint care. Orthopaedic Nursing, 17(5), 74-83.
Abstract: The implementation of clinical pathways in home care, along with the use of outcome tools and the development of benchmark physical therapy guidelines, is discussed in this article. Three tools were developed by an interdisciplinary team led by an orthopaedic surgeon and the clinical nurse specialist (CNS) in cooperation with several members of the home care staff.  (3 ref)

   82.    Korcz, I. R., & Moreland, S. (1998). Telephone prescreening: enhancing a model for proactive healthcare practice. Cancer Practice: a Multidisciplinary Journal of Cancer Care, 6(5), 270-5.
Abstract: PURPOSE: This article explicates the process of developing and implementing a contemporary, innovative program using the telephone as a tool for prescreening newly diagnosed cancer patients before their arrival at the cancer center. As another element of existing models of psychosocial care, this service lays the foundation for the efficient delivery of clinical social work services. DESCRIPTION OF PROGRAM: In the Surgical Oncology Clinic of the M.D. Anderson Cancer Center in Houston, Tex, 28 patients were contacted as part of a telephone prescreening model of a practice program from February 1, 1995 through March 31, 1995. Using a structured telephone interview format, two clinic social workers contacted patients and provided information on social work services. Patients needing resource assistance were provided with community referrals. Using the information from the telephone call, a brief outpatient assessment was completed for each patient before his or her arrival at the clinic. During the initial clinic visit, each new patient was met by the social worker to conduct a qualitative interview and address specific treatment-related concerns. OUTCOME OF PROGRAM: The patients expressed their appreciation of the interest of the social work staff and their satisfaction with the information provided. In addition, obtaining patient information and identifying patient needs before the initial visit allowed social workers to use clinic time more efficiently. Because of restructuring, the Surgical Oncology Clinic was eliminated and use of the intervention suspended. Based on the encouraging results of the telephone prescreening model of care program, reinstating the program in the future would include expanding its hours of operation to reach individuals who are not at home during the hours of 8:00 am 25:00 pm and including language assistance to address the needs of the increasingly multicultural population. CLINICAL IMPLICATIONS: Telephone prescreening is one strategy for personalizing psychosocial assessment. In this era of outpatient day surgery and cost-controlled managed healthcare, the benefits of prescreening are empowerment for both patients and multidisciplinary team members. The future holds promise for telephone prescreening to become part of the collaborative clinical pathways model of the disease-site centers concept.  (26 ref)

   83.    Keiser, J. F., & Howard, B. J. (1998). Critical pathways: design, implementation, and evaluation. Clinical Laboratory Management Review, 12(5), 317-32.
Abstract: As David M. Eddy, M.D., Ph.D., Senior Advisor for Health Policy and Management to Southern California Kaiser Permanente, discusses in his excellent book, Clinical Decision Making: From Theory to Practice (1), we are now in a time where we must rethink what we are doing and how we are doing it. Substantial variations among physicians in almost every aspect of the diagnostic process have been documented repeatedly, and these variations appear to cause patients to be treated differently. Eddy says these variations are not the fault of physicians or anyone else because of the complexity of the medical decision process. Nonetheless, the cost and quality of health care have suffered as a result. Numerous articles and individuals such as Jay McDonald, M.D., Professor and Chair of the Department of Pathology at the University at the University of Alabama at Birmingham Medical Center, also have highlighted these variables in practice patterns and their consequences (2). Dr. Eddy, Dr. McDonald, Michael G. Bissell, M.D., Ph.D., Director, Clinical Pathology, Allegheny General Hospital, Pittsburgh, Pennsylvania, and other leaders in the field have stressed the need for more standardization of health care; clinical decisions concerning diagnostic testing and therapeutic choices must be based on scientific evidence that demonstrates the practice being used is truly effective (1-6). This evidence, as well as other parameters discussed below, are known as outcomes. As expressed by Dr. McDonald, "there is a transition that is going on from doing what seems best to doing what one knows is best" (2). Practice guidelines and critical pathways now are seen by many as one solution to providing more standardization of health care and to meeting the demands of the rapidly changing medical environment for simultaneously increasing the quality of care while decreasing the costs.  (Abstract by: Author)

   84.    Hamadeh, G., Daher, M., & Bizri, A. R. (1998). Adapting guidelines to Lebanese clinical practice. [Review] [50 refs]. Journal Medical Libanais - Lebanese Medical Journal, 46(5), 261-7.

   85.    Deuschle, J. A., & Romeo, A. A. (1998). Understanding shoulder arthroplasty. Orthopaedic Nursing, 17(5), 7-17.
Abstract: This article discusses the vital role of the professional nurse when caring for patients who have shoulder replacement surgery. The indications for surgery, recent advances in the surgical procedure, postoperative management, and potential complications are reviewed.  (40 ref)

   86.    Baker, C. M., Miller, I., Sitterding, M., & Hajewski, C. J. (1998). Acute stroke patients comparing outcomes with and without case management. Nursing Case Management, 3(5), 196-203.
Abstract: Stroke represents a major human and economic challenge to society. The literature suggests that interdisciplinary clinical pathways maximize stroke patient outcomes, whether care is delivered in a designated stroke unit or in a general medical service. In this article, the authors describe the case management model implemented at Columbus Regional Hospital, a 325-bed rural referral hospital in southeastern Indiana. A retrospective chart review compared 23 patients with non-hemorrhagic strokes using two different models of care delivery: unit-based nursing case management and standard nursing care. Differences in outcomes are reported in relation to interdisciplinary utilization, timeliness of referrals, patient education, discharge dispositions, home safety assessments, next-site-of-care communications, length of hospital stay, and patient satisfaction

   87.    Zehr, K. J., Dawson, P. B., Yang, S. C., & Heitmiller, R. F. (1998). Standardized clinical care pathways for major thoracic cases reduce hospital costs. Annals of Thoracic Surgery, 66(3), 914-9.
Abstract: BACKGROUND: Standardized clinical care pathways have been developed for postoperative management in an attempt to contain costs in an era of rising health care costs and limited resources. The purpose of this study was to assess the effect of these pathways on length of stay, hospital charges, and outcome for major thoracic surgical procedures. METHODS: All anatomic lung (segmentectomy, lobectomy, and pneumonectomy) and partial and complete esophageal resections performed from July 1991 to July 1997 were retrospectively analyzed for length of stay, hospital charges, and outcome. A prospectively developed database was used. Clinical care pathways were introduced in March 1994. Comparisons were made between the procedures performed before (group I) and after (group II) pathway implementation. Common to both pathways are early mobilization and prudent x-ray and laboratory analysis. In addition, the pathway for esophagectomies emphasizes overnight intubation with 24-hour intensive care unit care, and staged diet advancement. The discharge goal was postoperative day 10. For lung resection the emphasis is early postoperative extubation with overnight intensive care unit management. The discharge goal was postoperative day 7. RESULTS: Group I esophagectomies (n = 56) had significantly greater hospital charges compared with group II (n = 96) ($21,977 +/- $13,555 versus $17,919 +/- $5,321; p < 0.04, in actual dollars) and ($29,097 +/- $18,586 versus $19,260 +/- $6,000; p < 0.001, in dollars adjusted for inflation) and greater length of stay (13.6 +/- 6.9 versus 9.5 +/- 2.8 days; p < 0.001). Group I lung resections (n = 185) had a significantly greater length of stay compared with group II (n = 241) (8.0 +/- 6.2 versus 6.4 +/- 3.8 days; p < 0.002); although charges trended downward ($13,113 +/- $10,711 versus $12,404 +/- $7,189; not significant) in actual dollars, charges were significantly less in dollars adjusted for inflation ($17,103 +/- $13,211 versus $13,432 +/- $8,056; p < 0.01). The most significant decreases in charges for esophagectomies were in miscellaneous charges (61% in dollars adjusted for inflation), pharmaceuticals (60%), laboratory (42%) and radiologic (39%) tests, physical therapy charges (35%), and routine charges (34%). For lung resections the greatest savings occurred for pharmaceuticals (38%), supplies (34%), miscellaneous charges (25%), and routine charges (22%). Mortality was similar (esophagectomies: I, 3.6%; II, 0%; lung resections: I, 0.5%; II, 0.8%; not significant). CONCLUSIONS: Introduction of standardized clinical pathways has resulted in a marked reduction of length of stay for all major thoracic surgical procedures. Total charges were reduced for both esophagectomies (34%) and lung resections (21%) with continued quality of outcome

   88.    Winter, B. (1998). Perioperative pathways for ambulatory surgery. Hospital Case Management, 6(9), 177-80.

   89.    Warner, B. W., Kulick, R. M., Stoops, M. M., Mehta, S., Stephan, M., & Kotagal, U. R. (1998). An evidenced-based clinical pathway for acute appendicitis decreases hospital duration and cost. Journal of Pediatric Surgery, 33(9), 1371-5.
Abstract: BACKGROUND/PURPOSE: In the pediatric population, appendicitis remains the most common surgical emergency encountered. The purpose of this study was to determine the impact of an evidence-based clinical pathway for acute appendicitis on patient care as well as hospital and home care costs at the authors' pediatric institution. METHODS: A prospective evaluation was conducted of an appendicitis clinical pathway (June 1996 through November 1996) compared with historical control patients (June 1994 through November 1994) not cared for by the pathway. RESULTS: Data (average +/- SD) for 120 pathway (P) patients were compared with 122 control (C) patients. Age (11.5 +/- 3.6 years for C v 11.2 +/- 3.9 years for P), rates of negative appendectomy (12.3% for C v 9.2% for P) and perforation (26.2% for C v 18.3% for P) were similar. Pathway patients with nonperforated appendicitis were more often discharged from the hospital within 24 hours (48% for C v 67% for P; P = .014) with lower hospital costs ($4,095 +/- $1,280 for C v $3,638 +/- $1,633 for P; P = .001). Pathway patients with perforated appendicitis had shorter hospitalization (185.2 +/- 59 hours for C v 113 +/- 44 hours for P; P = .0001) and lower hospital costs ($11,175 +/- $3,893 for C v $7,823 +/- $2,366 for P; P = .0001). CONCLUSION: An evidence-based appendicitis pathway decreased duration of hospitalization and cost without adversely affecting diagnosis or therapy. Clinical pathways for surgical diagnoses may prove useful as a means to minimize costs without compromising patient care

   90.    Smith, C. M., & Wigent, P. J. (1998). Pheochromocytoma in pregnancy: considerations for the advanced practice nurse. [Review] [32 refs]. Journal of Perinatal & Neonatal Nursing, 12(2), 11-25.
Abstract: Pheochromocytoma, a rare finding in pregnancy, is associated with significant risks for maternal fetal morbidity and mortality when undetected antenatally. The disease is commonly mistaken for hypertensive conditions of pregnancy. The advanced practice nurse may play a crucial role in early diagnosis based on a careful history and physical examination, clinical suspicion, diagnostic testing, and patient education. The management of a pregnant woman with pheochromocytoma is individualized for the woman, depending on gestational age, tumor location, and stabilization of the disease. A collaborative medical, surgical, and nursing team approach is needed. Pharmacologic intervention and surgical resection of the tumor(s) are the treatments of choice. Long-term followup is essential to detect malignancy and recurrence. [References: 32]

   91.    Sculco, T. P. (1998). Cost reduction in total joint arthroplasty. Orthopedics (Thorofare, NJ), 21(9), 1053-4.

   92.    Ringel, M., & Prior, M. (1998). Pathways lead to better management of asthma. Medical Management Network, 6(9), 1-4-suppl 6 p.

   93.    Monical, W. (1998). Managing high-risk pregnancies at home. Home Healthcare Consultant, 5(9), 28-31.
Abstract: A home care program for high-risk pregnancies that lengthens the gestational period and increases birth weight can result in a significant savings of health care resources. The design and implementation of an obstetric home management program should be approached in the same way as any other clinical business development endeavor. Critical pathways that reflect current standards of practice are just one element necessary to a comprehensive program. Other considerations on which the author touches include ethical issues and risk management.  (18 ref)

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

   95.    Krebs, T. L. (1998). Clinical pathway for enhanced parent and preterm infant interaction through parent education. Journal of Perinatal & Neonatal Nursing, 12(2), 38-49.
Abstract: The article discusses the importance of implementing a clinical pathway in the neonatal intensive care unit that emphasizes parent education. Through an extensive literature review, a clinical path was developed that incorporates parent education through an individualized, developmentally supportive model of interaction. The clinical path is designed to be utilized as a teaching tool from birth to discharge from the hospital. The path can serve as a guide for teaching and identifying learning objectives a long a time line as well as for providing consistent documentation

   96.    Isler, D. H. (1998). ClinCare: improving vascular outcomes through clinical care coordination. Journal of Vascular Nursing, 16(3), 45-7.
Abstract: In the current health care environment, increasing emphasis is being placed on the quality and financial outcomes of care by both consumers and third party payors. The ClinCare (registered service mark of Jewish Hospital, Louisville, Ky) program uses an interdisciplinary approach and data-driven decision making to improve the clinical management of specific high-risk patient populations across the continuum of care. The experience of the Vascular and Thoracic Surgery Clinical Practice Team is discussed with emphasis on clinical and financial outcomes

   97.    Eagle, K. A., Moscucci, M., Kline-Rogers, E., Chaffee, B. W., Barry, P. A., Roberts, S., Froehlich, J., Cornish, L. A., Wurster, H., & Deeb, G. M. (1998). Evaluating and improving the delivery of heart care: the University of Michigan experience. American Journal of Managed Care, 4(9), 1300-9.
Abstract: With increasing pressure to curb escalating costs in medical care, there is particular emphasis on the delivery of cardiovascular services, which account for a substantial portion of the current healthcare dollar spent in the United States. A variety of tools were used to improve performance at the University of Michigan Health System, one of the oldest university-affiliated hospitals in the United States. The tools included initiatives to understand outcomes after coronary bypass operations and coronary angioplasty through use of proper risk-adjusted models. Critical pathways and guidelines were implemented to streamline care and improve quality in interventional cardiology, management of myocardial infarction, and preoperative assessment of patients undergoing vascular operations. Strategies to curb unnecessary costs included competitive bidding of vendors for expensive cardiac commodities, pharmacy cost reductions, and changes in nursing staff. Methods were instituted to improve guest services and partnerships with the community in disease prevention and health promotion.  (Abstract by: Author)

   98.    Dexter, F., Macario, A., & Cerone, S. M. (1998). Hospital profitability for a surgeon's common procedures predicts the surgeon's overall profitability for the hospital. Journal of Clinical Anesthesia, 10(6), 457-63.
Abstract: STUDY OBJECTIVE: To evaluate whether a hospital's profitability for a surgeon's common procedures predicts the surgeon's overall profitability for the hospital. DESIGN: Observational study. SETTING: Community and university-affiliated tertiary hospital with 21,903 surgical procedures performed per year. PATIENTS: 7,520 patients having surgery performed by one of 46 surgeons. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Financial data were obtained for all patients cared for by all the surgeons who performed at least ten cases of one of the hospital's six most common procedures. A surgeon's overall profitability for the hospital was measured using his or her contribution margin ratio (i.e., total revenue for all of the surgeon's patients divided by total variable cost for the patients). Contribution margin was calculated twice: once with all of a surgeon's patients, and second, limiting consideration to those patients who underwent one of the six common procedures. The common procedures accounted for 22 +/- 15% of the 46 surgeons' overall caseload, 29 +/- 10% of their patients' hospital costs, and 30 +/- 12% of the hospital revenue generated by the surgeons. Hospital contribution margin ratios ranged from 1.4 to 4.2. Contribution margin ratios for common procedures and contribution margin ratios for all patients were correlated (tau = 0.58, n = 46, p < 0.0001). CONCLUSIONS: Even though most surgical cases were for uncommon procedures, a surgeon's hospital profitability on common procedures predicted the surgeon's overall financial performance. Perioperative incentive programs based on common surgical procedures (clinical pathways) are likely to accurately reflect a surgeon's financial performance on their other surgeries

   99.    Borgermans, L. A., Abraham, I. L., Milisen, K., Dejace, A. M., Gosset, C., & Rondal, P. M. (1998). Nursing case management for psychogeriatric patients and their families: description of a clinical model. [Review] [49 refs]. Nursing Clinics of North America, 33(3), 529-42.
Abstract: A theoretical model of clinical case management for psychogeriatric patients and their families is described. Psychogeriatric patients often have complex health care needs, requiring specific nursing interventions. The increasing frailty of these patients over time, together with the risk for institutionalization, make professional nursing contribution to their care even more desirable. Nursing case management is described by means of a conceptual-operational continuum. On the conceptual site, the continuum includes a geriatric definition and core principles of case management. On the operational site, case management is described as a clinical system, a process, a technology, and a role. The process of case management is a deliberate, intellectual activity whereby the practice of nursing is approached in an orderly, systematic manner. It includes components of assessment, diagnosis, planning, implementation, and evaluation. The case management approach requires nurses to assume an active role in designing care maps and to work collaboratively with members of a multidisciplinary team. [References: 49]

100.    Beyers, M. (1998). Ask AONE's experts ... about productivity indicators. Nursing Management, 29(9), 88.

101.    Bassano, J. M., & Schultz, G. D. (1998). Spinal fractures: a clinico-radiographic approach. Topics in Clinical Chiropractic, 5(3), 16-26, 66-68.
Abstract: Purpose: To review the radiology of spinal fractures and propose seed clinical pathways for determining the appropriateness of radiology of spinal trauma patients likely to present in chiropractic offices. Implications of appropriateness and timing of manipulation in spinal fractures are discussed. Method: A qualitative literature review was conducted, supplemented with clinical case review from files at the Los Angeles College of Chiropractic Radiology Department. Summary: Peak incidence of spinal fracture occurs in the young adult population with a male prevalence. However, females are predisposed to spinal fracture in the older population. The lumbosacral spine is the most frequent site for spinal fracture and is usually associated with falls and motor vehicle accidents. The nature of fracture is likely to induce characteristic changes in the anterior, middle, and posterior spinal column regions, serving as a guide for evaluating the radiograph. Adjustive methods may be appropriate in the posttraumatic therapeutic regimen depending on the nature and severity of trauma, the degree of heating, the amount of initial and residual deformation, and the neurologic status of the patient. An approach of passive and active movements of gradually increasing intensity may be therapeutically beneficial. Copyright (c) 1998 by Aspen Publishers, Inc.  (22 ref)

102.    Parsley, K. (1998). In search of pathways... clinical pathways. Nursing Times, 94(32), 40-1.
Abstract: How can clinical pathways benefit patient care? With her NT/BHSF travel award, Karen Parsley travelled across the world to learn how Australian clinicians implement the system.  (1 ref)

103.    Wang, T., Ackland, T., Hall, S., Gilbey, H., & Parsons, R. (1998). Functional recovery and timing of hospital discharge after primary total hip arthroplasty. Australian & New Zealand Journal of Surgery, 68(8), 580-3.
Abstract: BACKGROUND: Early discharge programmes in hospitals are encouraged to increase financial efficiency and bed availability, but standards of clinical care must not be compromised. Criteria for safe hospital discharge must be established and objective data are needed to assess how rapidly patients can achieve these discharge criteria. METHODS: A prospective study was performed on 65 patients (mean age = 71 years) scheduled for primary total hip arthroplasty (THA). The Modified Barthel Index (MBI) was measured pre-operatively and postoperatively at set intervals to asses recovery of function after THA. A score of 90 out of a possible 100 was used as a discharge criterion and indicated that the patient was functionally independent for safe hospital discharge. In addition, a combined score for thigh flexion and extension isokinetic peak strength was recorded for each patient before and after surgery. The number and nature of comorbidities and complications were also recorded. RESULTS: The length of hospital stay in this sample varied from 5 to 39 days. The MBI scores increased rapidly between days 3 and 5, then began to plateau from day 8 onwards. Based on the MBI, 58% of patients were fit for discharge at or before day 8. The remainder were fit for discharge from day 10 onwards (mean = 14.2 days). The latter group who required an extended hospital stay were older (P = 0.003), had more identified comorbidities (P = 0.01) and were weaker in their hip musculature prior to surgery (P = 0.001), compared to those who were discharged by day 8. A logistic regression analysis indicated that the pre-operative MBI score and hip strength score were strong predictors of timing for hospital discharge. CONCLUSIONS: A clinical pathway with functional milestones laid out over 8 days would be an appropriate criterion for the discharge of the majority of patients. However, approximately 40% of the patients presented in this study required a longer hospital stay before the criteria for safe discharge could be achieved. These patients can be identified pre-operatively by screening their MBI and composite hip strength scores

104.    Rosborough, D. M., Fisher, D. G., & Cohn, L. H. (1998). Pathway for uncomplicated cardiac surgical patients. Hospital Case Management, 6(8), 157-60.

105.    Machacyk, C. A. (1998). Taking the right pathway. Critical pathways are a road map to care. Provider, 24(8), 67-8.

106.    Lusky, K. F. (1998). Real treatment options for incontinence. Condition is no longer a given in the aging process. Provider, 24(8), 42-4-47.

107.    Lanska, D. J. (1998). The role of clinical pathways in reducing the economic burden of stroke. [Review] [22 refs]. Pharmacoeconomics, 14(2), 151-8.
Abstract: Clinical pathways are a potentially beneficial, but largely untested, management strategy for both improving healthcare efficiency and decreasing costs while also maintaining or improving quality of care. Although relatively few clinical pathways for stroke have been described in the medical literature and although the reported benefits have been mixed, more and more hospitals are adopting clinical pathways as a management strategy for patients with stroke. In published clinical pathways for acute stroke, the following benefits have been reported: (i) reduced use of expensive diagnostic studies; (ii) fewer complications (particularly the frequency of urinary tract infections and aspiration pneumonia); (iii) reduced duration of hospital stay; (iv) reduced patient charges; and (v) lower mortality. However, these reported benefits are not consistent across all studies and some outcomes are highly correlated. Despite potential benefits, many clinical pathway programmes fail because of inadequate planning and shortcomings of implementation. Effective implementation of clinical pathways requires strong administrative and medical staff leadership, active participation of all clinical disciplines involved in the care of patients on the pathway, provision of regular feedback to clinicians, sufficient resources, improved documentation, incorporation of the entire episode of care into the pathway, integration with ongoing quality and utilisation management programmes, and periodic evaluation and modification.  (22 Refs)  (Abstract by: Author)

108.    Kane, R. L. (1998). Managed care as a vehicle for delivering more effective chronic care for older persons. Journal of the American Geriatrics Society, 46(8), 1034-9.
Abstract: Chronic illness is now the dominant feature of health care, and its impact will grow with the aging of the population. Managed care could provide an environment conducive to better care for chronically ill patients. A precondition for these activities is a shift in Medicare payment approaches to managed care organizations to recognize differences in risk. To improve care for the chronically ill, changes need to occur in two major areas: (1) The approach to chronic care needs to become more aggressive, with higher expectations about the benefits from care (even if measured by slowing the rate of decline), and (2) an information infrastructure is needed to help focus clinicians' attention on changes in patients' status. Some of these changes may eventually evolve spontaneously in managed care's search for more efficient ways of meeting its service obligations, but external forces, such as certification and federal mandates, could catalyze the transition

109.    Johnson, D. I., Mooney, K., DiStefano, M., Sullivan, M., Haber, D., & Kalriess, G. (1998). Using hospital information systems to manage outcomes. Journal of Nursing Care Quality, 12(6), 37-47.
Abstract: This article discusses techniques used at Staten Island University Hospital to help automate manual data collection for performance improvement reports and outcomes analysis. If data must be collected manually, it is time to take a look at information available in your hospital's information system

110.    Bohmer, R. (1998). Critical pathways at Massachusetts General Hospital. Journal of Vascular Surgery, 28(2), 373-7.

111.    Barrella, P., & Della Monica, E. (1998). Managing congestive heart failure at home. [Review] [24 refs]. AACN Clinical Issues, 9(3), 377-88.
Abstract: The hospital readmission rate and associated cost of treating patients with heart failure continues to escalate. Hospitals now regard home care as an alternative to institutional care for mthe long-term management of heart failure. Heart failure management programs are becoming increasing popular in home care as home health agencies strive to meet the demands of the Medicare managed-care environment. Practice standards such as those of the Agency for Health Care Policy and Research (AHCPR), form a basis by which home health agencies can develop, implement, and evaluate their program. Heart failure management continues to improve with advances made toward decreasing morbidity and mortality. The cardiac home care nurse assumes a pivotal role in the management of these complex patients. [References: 24]

112.   Pryse-Phillips, W. E., Dodick, D. W., Edmeads, J. G., Gawel, M. J., Nelson, R. F., Purdy, R. A., Robinson, G., Stirling, D., & Worthington, I. (1998). Guidelines for the nonpharmacologic management of migraine in clinical practice. Canadian Headache Society [see comments]. CMAJ, 159(1), 47-54.
Notes: Comment in: ACP J Club 1999 Jan-Feb;130(1):11, Comment in: CMAJ 1999 Jan 12;160(1):21-2
Abstract: OBJECTIVE: To provide physicians and allied health care professionals with guidelines for the nonpharmacologic management of migraine in clinical practice. OPTIONS: The full range and quality of nonpharmacologic therapies available for the management of migraine. OUTCOMES: Improvement in the nonpharmacologic management of migraine. EVIDENCE AND VALUES: The creation of the guidelines followed a needs assessment by members of the Canadian Headache Society and included a statement of objectives; development of guidelines by multidisciplinary working groups using information from literature reviews and other resources; comparison of alternative clinical pathways and description of how published data were analysed; definition of the level of evidence for data in each case; evaluation and revision of the guidelines at a consensus conference held in Ottawa on Oct. 27-29, 1995; redrafting and insertion of tables showing key variables and data from various studies and tables of data with recommendations; and reassessment by all conference participants. BENEFITS, HARMS AND COSTS: Augmentation of the use of nonpharmacologic therapies for the acute and prophylactic management of migraine is likely to lead to substantial benefits in both human and economic terms. RECOMMENDATIONS: Both the avoidance of migraine trigger factors and the use of nonpharmacologic therapies have a part to play in overall migraine management. VALIDATION: The guidelines are based on consensus of Canadian experts in neurology, emergency medicine, psychiatry, psychology and family medicine, and consumers. Previous guidelines did not exist. Field testing of the guidelines is in progress

113.    Tumbarello, C. (1998). Ultrasound evaluation of abdominal trauma in the emergency department. [Review] [21 refs]. Journal of Trauma Nursing, 5(3), 67-72; quiz 79-80.
Abstract: To review the use of ultrasound for assessment of abdominal trauma during the secondary assessment. Three current methods for evaluation of abdominal trauma will be outlined. The use of ultrasound in evaluation of patients with blunt abdominal trauma will be highlighted, including performance of test, time to test completion, strengths, and limitations. The use of serial examination utilizing focused abdominal sonography for blunt trauma (FAST) to evaluate hemoperitoneum will be presented. [References: 21]

114.    Miller, K. H., Grindel, C. G., & Patsdaughter, C. A. (1998). Impact of risk classification on nursing resource utilization, postoperative length of stay, and hospital costs for cardiac surgical patients. Outcomes Management for Nursing Practice, 2(3), 117-23.
Abstract: Outcomes after cardiac surgery are a concern for patients, health care providers, and insurers. Because of the current economic climate, there is a demand for positive outcomes and an evaluation of negative results. The results of this study showed significant differences in nursing resource utilization, postoperative length of stay, and hospital costs by risk classification group. Risk classification models could serve as a template for staffing patterns and reimbursement based on patients' clinical profiles.  (21 ref)

115.    Hollingsworth-Fridlund, P., Hall, J. B., Stout, P., Russell, M., Kaney, M. C., & Hoyt, D. B. (1998). The nonoperative injury pathway. Journal of Trauma Nursing, 5(3), 75-8.

116.    Zander, K. (1998). Concurrent review. Morphing case management. Case Manager, 9(4), 4.

117.    Sexauer, L. F., & Hogan, M. P. (1998). Application of a prototype process for developing a tube gastrostomy clinical pathway. Gastroenterology Nursing, 21(4), 162-72.
Abstract: The development and implementation of clinical pathways as a managed care tool have been widely embraced as principal components of the healthcare industry's drive to reform costly, inconsistent, and often uncontrolled delivery of services. Clinical pathways are not new to healthcare; however, the lack of a defined and systematic process for pathway development has hindered organizational efforts to develop and implement clinical pathways. A multidisciplinary clinical pathway process prototype was identified as a means for effectively defining and linking care and outcomes for patients requiring tube gastrostomy placement at a large military medical facility. This article presents the prototype process for developing a clinical pathway with a practical application to illustrate the process and provides a process template for potential use by others interested in developing multidisciplinary clinical pathways

118.    Sagarin, M. J., Cannon, C. P., Cermignani, M. S., Scirica, B. M., & Walls, R. M. (1998). Delay in thrombolysis administration: causes of extended door-to-drug times and the asymptote effect. Journal of Emergency Medicine, 16(4), 557-65.
Abstract: We retrospectively analyzed medical records and critical pathway data forms of all patients who received thrombolytic therapy for acute myocardial infarction (AMI) over a 2 1/2-year period. The time spent by each patient in the emergency department (ED) prior to receiving thrombolytic therapy (the door-to-drug time) was determined. Records of those patients with door-to-drug times exceeding the median were closely examined to determine the cause of treatment delays. Results indicated that treatment delays resulted from delays in obtaining the initial electrocardiogram (24%), atypical presentations (11%), the need to rule out a potential contraindication (11%), the need to confirm the diagnosis (14%), and miscellaneous causes (8%). Many patients had no identifiable reason for their delay (32%). A certain population of AMI patients either do not satisfy thrombolytic criteria upon initial ED presentation or require prolonged evaluation to investigate possible contraindications to thrombolysis such as aortic dissection. The inclusion of patients in this separate population in a general analysis of median door-to-drug times results in an artificial asymptote effect and may confound quality initiatives

119.    Miracle, P., Savage, T., Hickey, T., Mountjoy, B., & Martin, P. A. (1998). Designing a system for ambulatory obstetric case management. Nursing Case Management, 3(4), 160-7.
Abstract: The authors describe the development of critical pathways for ambulatory obstetric case management. When case management was identified as needed, but published work in outpatient obstetrics could not be found, four nurses used this opportunity to design a cost-effective system leading to quality outcomes. The driving force was the need for a format that directed comprehensive consistent care delivered by a large multidisciplinary health care team. Design issues included capturing leading edge standards of care and user friendly formats for all caregivers. Throughout a period of 2 years, a trifold format was developed for all obstetric patients, and 15 bifold formats were developed for patients with specific high-risk diagnoses. The format design facilitated cost-effective quality care and is expected to improve patient outcomes. A research study has been initiated to measure effectiveness of the design.  (13 ref)

120.    Kroll, S. (1998). Patient care pathways and the CM in acute care. Case Manager, 9(4), 37-41.

121.    Bailey, D. A., Litaker, D. G., & Mion, L. C. (1998). Developing better critical paths in healthcare: combining 'best practice' and the quantitative approach. Journal of Nursing Administration, 28(7-8), 21-6.
Abstract: Critical paths are tools to manage healthcare delivery and ensure favorable patient outcomes. Unfortunately, many of these paths are not evaluated or revised after their initial development. One potential problem faced by nursing managers is that critical paths may lose relevance in a rapidly changing healthcare environment. The authors suggest one strategy to strengthen existing critical paths in a way that is responsive to these changes

122.    Worwag, E., & Chodak, G. W. (1998). Overnight hospitalization after radical prostatectomy: the impact of two clinical pathways on patient satisfaction, length of hospitalization, and morbidity. Anesthesia & Analgesia, 87(1), 62-7.
Abstract: Changes in health care have prompted efforts to reduce length of hospitalization while maintaining quality care. Therefore, we evaluated short-term outcomes after radical retropubic prostatectomy on 100 consecutive men undergoing surgery for clinically localized prostate cancer performed under epidural anesthesia followed by epidural morphine or combined with spinal anesthesia using bupivacaine and fentanyl (25 micrograms) and followed by i.m. methadone (10-20 mg). All patients received oral acetaminophen and ibuprofen beginning 4 h after surgery. Length of hospital stay, responses to written satisfaction survey, postoperative morbidity and readmission to the hospital were recorded. Using either pathway, 83% of the patients were discharged after one night in the hospital. The mean hospital stay was 1.34 +/- 1.10 and 1.28 +/- 1.0 days, respectively. Although three men were rehospitalized, it was not because of the early discharge. More than 95% of patients were satisfied with pain control, and patients discharged after one night were not more likely to be dissatisfied than patients hospitalized longer. Implications: Both clinical pathways provide excellent anesthesia and analgesia and allow discharge 1 day after radical retropubic prostatectomy. Shortened hospital stay does not increase patient dissatisfaction or add to postoperative morbidity. Patients undergoing other pelvic and abdominal operations may also derive similar benefits using these pathways

123.    Wells, N., Johnson, R., & Salyer, S. (1998). Interdisciplinary collaboration [see comments]. Clinical Nurse Specialist, 12(4), 161-8.
Notes: Comment in: Clin Nurse Spec 1998 Jul;12(4):160
Abstract: This quasiexperimental study investigated interdisciplinary collaboration over a 16-month period on units using different collaborative practice strategies. Measures of collaboration and perceived physician involvement in collaborative practice were completed by 335 licensed staff members working on seven general adult units in an acute care hospital located in an academic medical center. Data were collected at two time points: in 1993 and 1995. A small but statistically significant decline in collaboration was found (p = 0.01) over the 16-month period. Analysis of variance revealed a significant difference (p = 0.03) in collaboration related to the method used to develop collaborative paths. Post hoc Tukey's test indicated that the presence of a case manager without collaborative paths did show higher levels of collaboration (p = 0.05). Regardless of the strategy used, perceived high physician involvement was related to greater collaboration than perceived low involvement with differences increasing over time (p = 0.02). These findings suggest the importance of perceived physician involvement in collaborative practice to interdisciplinary collaboration

124.    Uto, Y., Muranaga, F., & Kumamoto, I. (1998). Creating clinical path based on analysis using hospital information system. Japan-Hospitals, 17, 37-43.

125.    Spain, D. A., McIlvoy, L. H., Fix, S. E., Carrillo, E. H., Boaz, P. W., Harpring, J. E., Raque, G. H., & Miller, F. B. (1998). Effect of a clinical pathway for severe traumatic brain injury on resource utilization. Journal of Trauma-Injury Infection & Critical Care, 45(1), 101-4; discussion 104-5.
Abstract: BACKGROUND: The usefulness of clinical pathways for the complex trauma patient is unclear. We analyzed the effect of a clinical pathway for severe traumatic brain injury (TBI) on resource utilization. METHODS: A clinical pathway for severe TBI (Glasgow Coma Scale (GCS) score < or = 8 at 24 hours) was developed by a multidisciplinary team and used for all patients with severe TBI. Data were gathered prospectively for 15 months and compared with data from historical controls from the previous year. Patients who survived < 48 hours were excluded. RESULTS: The clinical pathway was used for 84 patients with severe TBI and compared with 49 historical controls. No differences in Injury Severity Scores (27 vs. 27) or GCS scores at 24 hours (6.2 vs. 6.5) existed between control or pathway patients. There was an overall increase in the mortality rate of pathway patients (from 12.2 to 21.4%), but this was entirely attributable to withdrawal of care that was initiated by family members in patients with an average age of 71 years, an average GCS score of 4.7, and an average Injury Severity Score of 29. Among survivors, pathway patients had a significant decrease in ventilator days (11.5 +/- 0.9 vs. 14.6 +/- 1.2; p < 0.05), intensive care unit days (16.7 +/- 1.0 vs. 21.2 +/- 1.4; p < 0.05), and hospital days (23.4 +/- 1.2 vs. 31.0 +/- 3.0; p < 0.05). There were no differences in the incidence of complications or functional outcomes. CONCLUSION: The use of a clinical pathway for severe TBI resulted in a significant reduction in resource utilization. This study suggests that clinical pathways may be a useful component of patient care after blunt trauma

126.    Paul, L. (1998). Power shift. A new model for case management returns power to physicians--and still promises to cut costs. Healthcare Informatics, 15(7), 27-8.

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

128.    Mitchel, J. V. (1998). A clinical pathway for ostomy care in the home: process and development. [Review] [13 refs]. Journal of Wound, Ostomy, & Continence Nursing, 25(4), 200-5.
Abstract: The health care environment is changing rapidly both in form and funding. Recognition of the need for organized, cost-efficient services across the health care continuum has resulted in a model identified as a clinical pathway. This article compares and contrasts key elements of the clinical pathway model as they apply to the acute care setting versus the home care setting. An example of a clinical pathway for ostomy patients in the home care setting is presented, followed by a discussion of its development, pilot testing, and outcomes evaluation. Conclusions regarding the validity of clinical pathways in home care are discussed, and the need for further research is considered. [References: 13]

129.    Miller, K. H. (1998). Factors influencing selected lengths of ICU stay for coronary artery bypass patients. Journal of Cardiovascular Nursing, 12(4), 52-61.
Abstract: This study examines factors influencing the length of intensive care unit stay for patients after coronary artery bypass surgery. Profiles of patients with selected lengths of ICU stay were identified for Group 1 (< or =1 day) and Group 2 (> or =2 days). Medical records of 175 patients who had undergone this procedure at an urban teaching hospital were reviewed. Patients who had a 1-day ICU length of stay were younger (mean=62.39, SD=10.88) and had comorbidities such as hypertension. Those patients with an ICU length of stay 2 days or longer were older (mean=68.18, SD=11.84) and had preoperative comorbidities such as congestive heart failure, chronic obstructive pulmonary disease, ejection fraction <50%, and need for an intra-aortic balloon pump. Atrial dysrhythmias, low cardiac output syndrome, renal insufficiency, and respiratory insufficiency were the postoperative complications associated with a prolonged ICU length of stay. Knowledge of the factors influencing selected lengths of ICU stay will enable nurses to choose patients for critical pathways and to anticipate postoperative problems in high-risk patients

130.    Kimball-Baker, K. (1998). PharmAid. Healthcare Informatics, 15(7), 48-52,54,56.

131.    Holland, B. S. (1998). Mother/baby short-stay pathway complements merger. Hospital Case Management, 6(7), 137-40.

132.    Fortier, J., Chung, F., & Su, J. (1998). Unanticipated admission after ambulatory surgery--a prospective study. Canadian Journal of Anaesthesia, 45(7), 612-9.
Abstract: PURPOSE: To determine the incidence, the reasons, and the predictive factors for unanticipated admission after ambulatory surgery. METHODS: Preoperative, intraoperative, and postoperative data were collected prospectively on 15,172 consecutive ambulatory surgical patients during a 32-month period. The data were built into a statistical model, and predictive factors were identified and classified. RESULTS: The overall incidence of unanticipated admission was 1.42%. Admitted patients were more likely to be older, male, and ASA status II or III. Duration of anaesthesia was longer, and surgery was more likely to be completed after 3 pm. Length of stay in the Postanaesthesia Care Unit and the Ambulatory Surgery Unit was longer. Surgical reasons were cited in 38.1% of admitted patients; anaesthesia-related reasons were cited in 25%; social reasons accounted for 19.5%, and medical reasons for 17.2%. Ear, nose and throat (ENT) patients had the highest unanticipated admission rate (18.2%), followed by urology (4.8%) and chronic pain block (3.9%). Gynaecological patients had the lowest rate (0.4%). Among the predictive factors found were male, ASA status II and III, long duration of surgery, surgery finishing after 3 pm, postoperative bleeding, excessive pain, nausea and vomiting, and excessive drowsiness or dizziness. CONCLUSION: Earlier operating time for certain surgical procedures, screening for proper support at home, and implementation of clinical pathways to deal aggressively with problems such as pain, nausea and vomiting should decrease the incidence of unanticipated admission

133.    Drew, R. H. (1998). Programs promoting timely sequential antimicrobial therapy: an American perspective. [Review] [58 refs]. Journal of Infection, 37(Suppl 1), 3-9.
Abstract: Interventional programs promoting the timely conversion of intravenous to oral antimicrobial therapy have been reported from several hospitals in the U.S.A. and elsewhere. Factors influencing the initiation and conduct of these programs include technological advances, changes in health care delivery or reimbursement, publication of supportive clinical data and growth of clinical pharmacy services. Successful programs employ comprehensive, multidisciplinary strategies to contain antimicrobial-related expenditures using interventions based on structured criteria. Future emphasis on cost-effective drug therapy, advances in computer-based information technology and development of care maps can have favourable influences on the growth of these programs in the U.S.A. [References: 58]

134.    Cowell, V. L., Ciraulo, D., Gabram, S., Lawrence, D., Cortes, V., Edwards, T., & Jacobs, L. (1998). Trauma 24-hour observation critical path. Journal of Trauma-Injury Infection & Critical Care, 45(1), 147-50.
Abstract: BACKGROUND: The 24-hour observation critical pathway for trauma is a clinical tool developed to expedite health care delivery to minimally injured patients. The use of patient care, BS, guidelines and physician-approved standing orders was implemented in a Level I trauma center. METHODS: A retrospective chart review was performed of 122 patients admitted via the emergency department between December 1, 1993, and May 31, 1994. All patients were evaluated in the emergency department by emergency medicine and trauma physicians and deemed appropriate for 24-hour observation. The information collected included patient demographics, hospital charges, injuries, length of stay, diagnostic tests, consultations, and variances from the critical pathway. RESULTS: During the 6-month study period, there were 600 trauma admissions. Of those admissions, 122 patients (20%) were evaluated in the emergency department and deemed appropriate for enrollment in the 24-hour observation pathway. The charts of these patients were reviewed. Fourteen admissions were determined inappropriate for the critical pathway because of the severity of injuries or discharge against medical advice. One hundred eight charts were evaluated further. Eighty-nine patients (80%) completed the critical pathway with a length of stay of 24 hours. CONCLUSION: The 24-hour observation critical pathway was designed and used appropriately as exemplified by an overall 80% completion rate. The critical pathway offers a mechanism to streamline care of the minimally injured trauma patient. It also serves as a quality-improvement tool for increasing efficiency, decreasing utilization of resources, and decreasing length of stay

135.    Chu, S., & Cesnik, B. (1998). Improving clinical pathway design: lessons learned from a computerised prototype. International Journal of Medical Informatics, 51(1), 1-11.
Abstract: Increasing costs of health care, fuelled by demand for high quality, cost-efficient health care has propelled hospitals to restructure their patient care delivery systems. One such effort is the adaptation of an engineering project management methodology, the critical path method (CPM), as a tool to organise, standardise and improve the quality of healthcare delivery and hence patient outcomes. However, the two-dimensional nature and the size of paper impose severe limitations on the manual clinical pathways currently in use by hospitals. This paper analyses these inherent limitations and discusses some of the problems encountered in an attempt in early 1996 to create an electronic care map planner (CMP) based on the precedence diagramming method (PDM) model. It also reports on a current project to create a computerised clinical pathway tool to resolve the identified problems

136.    Cheah, T. S. (1998). The impact of clinical guidelines and clinical pathways on medical practice: effectiveness and medico-legal aspects. [Review] [37 refs]. Annals of the Academy of Medicine, Singapore, 27(4), 533-9.
Abstract: The 1990s will be remembered as a decade when quality assurance, evidence-based medicine and clinical quality improvement became key issues in the delivery of health care in hospitals and community settings. As public expectations of high quality health care increase in the face of diminishing resources and as accountability and standardisation of clinical practice are demanded by both consumers and professional regulatory bodies, the medical profession has responded with a proliferation of clinical practice guidelines and pathways. The efforts have been spearheaded by the various professional and academic colleges. Despite all the enthusiasm that has been created, there is still uncertainty regarding the clinical effectiveness, validity and medico-legal effects of practice guidelines and clinical pathways. This article focuses on the reasons behind the increasing popularity of clinical guidelines and pathways, a critical appraisal of their effectiveness and the medico-legal implications, effects and consequences of implementing such guidelines in clinical practice. [References: 37]

137.    Branney, S. W., Moore, E. E., Feldhaus, K. M., & Wolfe, R. E. (1998). Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center. Journal of Trauma-Injury Infection & Critical Care, 45(1), 87-94; discussion 94-5.
Abstract: BACKGROUND: Despite numerous studies, no clear consensus exists for the optimal use of emergency department thoracotomy (EDT). As such, we have continued to critically review our experience with EDT during the last 23 years to clarify indications for EDT and evaluate its cost-effectiveness. METHODS: This was a retrospective review of 950 EDTs performed at our regional Level I trauma center during the last 23 years. Cost-benefit ratios were calculated using standardized models. RESULTS: In 23 years, 950 patients underwent postinjury thoracotomy. We were able to obtain the complete medical records for 868 patients (91%). Overall survival was 4.4%, with 3.9% surviving functionally intact. All survivors of blunt trauma had either palpable pulse or recorded blood pressure in the field. Blunt trauma functional survival when field vital signs were present was 2.5%. Of note, 26.5% of our functional survivors sustained penetrating injuries and had no pulse or blood pressure in the field. Stab wounds to the chest and gunshot wounds to the abdomen were the two mechanisms of injury most likely to be survived. The benefit-charge ratio was strongly in favor of performing EDT at 5.6:1; it was 1.8:1 if adjusted for the cost of maintaining all neurologically injured survivors throughout their lifetime. CONCLUSION: EDT is efficacious and cost-effective for select patient populations. We suggest a key clinical pathway for the use of EDT that would reduce the number of procedures by at least 32% without changing the number of neurologically intact survivors

138.    Bowers, C. W. (1998). Development and implementation of evidence-based guidelines: a multisite demonstration project. Journal of Wound, Ostomy, & Continence Nursing, 25(4), 187-93.
Abstract: The development of alternative patient care delivery systems is being explored by health care providers, managed care corporations, insurance companies, and the government. Pathways, guidelines, care maps, and algorithms are techniques that assist in the development of patient care delivery systems with the potential to both decrease cost and ensure quality. This article reviews our experience with a program designed to transport clinical guidelines and pathways developed from evidence-based scientific knowledge to 7 acute care facilities located throughout the United States

139.    Bernardo, A. (1998). Technology and true presence in nursing. Holistic Nursing Practice, 12(4), 40-9.
Abstract: If there is to be a future for nursing in the next millenium, it must be dictated not by technologic advances directly but by the manner in which technology relates with persons in health and illness. Technology enables nurses to care for persons in a more efficient and cost-effective manner. True presence, as articulated in the human becoming theory, affords members of the profession opportunities to be with persons in ways that make a difference to their quality of life. The article illustrates the recognition of the link between technology and true presence through the use of a nurse-person encounter. Copyright (c) 1999 by Aspen Publishers, Inc.  (33 ref)

140.    Silverstein, W. (1998). Care management the right balance of care and management?. [Review] [5 refs]. Nursing Administration Quarterly, 22(4), 66-75.
Abstract: In 1990, nursing leadership at St. Peter's Medical Center, realizing a need to be creative in order to meet the cost and quality demands of the ever-changing health care system, developed a case management system model called Care Management. The qualifications for the role and the orientation of the Care Managers is describes changes in the program. Innovative programs integrated into the model include patient pathways, workers' compensation care management, and ambulatory care management. Outcomes described include length stay and cost reductions. Future direction of the program in the continuum of care is reviewed. [References: 5]

141.    Hill, M. (1998). The development of care management systems to achieve clinical integration. Advanced Practice Nursing Quarterly, 4(1), 33-9.
Abstract: With development of managed care markets, health care delivery systems face increasing clinical and financial risk. For an integrated delivery system to survive, strategies for clinical integration and care management are essential. CareMap tools, collaborative practice groups, and case management serve as the foundation to accomplish care management over the health continuum. Coordination of care, within an institution and across traditional health settings, to achieve the best clinical and cost outcomes is the goal. The article discusses strategies for clinical integration, categories for measurement of performance, and the need to incorporate automated solutions into the strategic business plan

142.    Finlayson, R. E. (1998). Prescription drug dependence in the elderly: the clinical pathway to recovery. Journal of Mental Health & Aging, 4(2), 233-49.
Abstract: Prescription drug use, abuse and dependence in elderly persons present a difficult challenge for clinicians, pharmacists and others involved in the care of this population. Existing diagnostic models fall short in identifying the problem amid the cormorbidities of old age. Additionally, we lack tested models for treatment of the problem. The author, in this paper, attempts to build a rational and conceptual model for treatment of prescription drug dependence in the elderly based upon Clinical Pathways and case management concepts. Three care histories are reported which illustrate the importance of Clinical Pathway events, things that often happen during the phase of recovery commonly referred to as aftercare. The events may adversely affect the recovery unless they are well managed by the attending physician or other clinicians involved in the case. Identification of potential pathway events during the formal programmatic phase of addition treatment is helpful in planning strategies to deal with these events as they occur.  (33 ref)

143.    Bridge, G. E., & Norris, A. C. (1998). Care pathways in the in the quality management of UK healthcare. Informatics in Healthcare Australia, 7(1), 22-7.

144.    Zielinski, S., Pavey, S., & Dunham, S. (1998). Dobutamine stress echocardiogram: emergency department evaluation of chest pain. Journal of Emergency Nursing, 24(3), 240-6.

145.    Weingarten, S. (1998). Intranet application has all the right stuff for guideline development. Medical Management Network, 6(6), 6-7.

146.    Weaver, F. M., Guihan, M., Hynes, D. M., Byck, G., Conrad, K. J., & Demakis, J. G. (1998). Prevalence of subacute patients in acute care: results of a study of VA hospitals. Journal of Medical Systems, 22(3), 161-72.
Abstract: Subacute care is a transitional level of care for medically stable patients who no longer require daily diagnostic/invasive care but require more intensive care than is typical in a skilled care facility. A Congressionally mandated study was undertaken to determine the number of VA patients with subacute needs being cared for in acute care. InterQual, Inc. subacute care criteria were retrospectively applied to 858 medical and surgical admissions from 43 VA hospitals. Over one-third contained at least one subacute day; with an average length of stay (LOS) of 12.7 days (SD = 12.4); of which 6.8 days were subacute. Patients with these admissions had significantly longer LOSs, were older, and were more likely to die or to be discharged to a nursing home. Diagnoses with subacute days included COPD, pneumonia, joint replacement, and cellulitis. Future studies should develop clinical pathways to prospectively manage admissions with subacute needs and then evaluate their effectiveness

147.    Tucker, J. (1998). Shared governance model benefits case management program... "Being led down the critical pathway: a perspective on the importance of care managers vs critical care pathways for patients requiring prolonged mechanical ventilation," Pulmonary Column, December 1997. Critical Care Nurse, 18(3), 27, 98.

148.    Szarzanowicz, A. (1998). Integrate patient care with chemical dependency pathways. Hospital Case Management, 6(6), 117-20.

149.    Steinberg, J. R. (1998). High-dose chemotherapy and autologous stem call [sic] reinfusion for breast cancer: specialized outpatient clinic. Home Healthcare Consultant, 5(6 Oncology), 2-8.
Abstract: One of the most important forces driving health care today is economics. This article describes the application of two cost-saving strategies (critical pathway and outpatient treatment) to an intensive therapy: autologous bone marrow transplantation for breast cancer. The challenge was to modify the existing critical pathway to accommodate outpatient therapy. Clinical issues tackled by the interdisciplinary team included timing of prophylactic antibiotic administration, nausea and vomiting control, mucositis pain control, parenteral nutrition, and empiric antibiotic administration for neutropenic fever.  (13 ref)

150.    Stanley, A. C., Barry, M., Scott, T. E., LaMorte, W. W., Woodson, J., & Menzoian, J. O. (1998). Impact of a critical pathway on postoperative length of stay and outcomes after infrainguinal bypass [see comments]. Journal of Vascular Surgery, 27(6), 1056-64; discussion 1064-5.
Notes: Comment in: J Vasc Surg 1999 Feb;29(2):385-6
Abstract: PURPOSE: To determine the effect of a critical pathway on postoperative length of stay and outcomes after infrainguinal bypass. METHODS: A critical pathway for care of patients after infrainguinal bypass was introduced in December 1995 to coordinate postoperative care at our institution. We compared care of 67 consecutively treated patients before institution of the pathway with care of 69 consecutively treated patients with the critical pathway in place. Data collection was done by means of chart review. Univariate analyses were used to identify differences between prepathway and postpathway patients and to identify factors influencing postoperative length of stay. Multivariate analysis was used to identify factors that influenced length of stay and to examine the effect of use of the pathway after adjusting for other factors. RESULTS: Patients on the pathway were similar to prepathway controls with respect to comorbid illnesses, vascular risk factors, indications for surgical treatment, type of conduit, and type of operation. Factors associated with longer postoperative stays included distal anastomoses to tibial rather than popliteal vessels (p = 0.02), preexisting cardiac disease (p = 0.005), postoperative complications (p = 0.0003), lower preoperative hematocrit (p = 0.01), and elevated preoperative creatinine level (p = 0.006). Overall, pathway patients had somewhat shorter postoperative lengths of stay (median value 7 days; range 2 to 29 days) than prepathway patients (median value 6 days; range 2 to 35; p = 0.01), and the two groups had similar frequencies of postoperative complications, readmission, and 6-month mortality. However, patients on the pathway were more likely to be discharged to an intermediate-care facility rather than directly home. After 12 patients with extraordinarily prolonged postoperative stays were excluded, multivariate analysis indicated that pathway patients had significantly shorter postoperative stays (p = 0.001). However, the difference was not significant if patients with extraordinarily long postoperative stays were included in the analysis (p = 0.28). CONCLUSION: Use of a critical pathway was associated with a modest decrease in postoperative length of stay for most patients. This was accomplished without an adverse effect on readmission, complication, or mortality rates. However, the decrease in stay may have been achieved primarily by discharging more patients to intermediate-care facilities. The pathway did not appear to have any effect when the subset of patients with extraordinarily long stays because of complex medical problems was included

151.    Preiss, D. J. (1998). The young child with sickle cell disease. [Review] [15 refs]. Advance for Nurse Practitioners, 6(6), 32-9.
Abstract: Approximately 2,000 infants with sickle cell disease are born each year in the United States. Sickle cell disease is an inherited disorder of red blood cell hemoglobin. Sickle cells increase adhesion and cause blockage in the small blood vessels, resulting in tissue damage. The cells' production of hemoglobin S results in two major pathophysiologic features of sickle cell disorders: chronic hemolytic anemia and vaso-occlusion. These disorders cause ischemic tissue damage and acute and chronic organ failure. Potential complications for children with sickle cell disease include vaso-occlusive events, splenic sequestration, bacterial septicemia from splenic hypofunction, aplastic crisis, pulmonary compromise including acute chest syndrome, renal tubular dysfunction and renal failure, priapism, aseptic necrosis, gallstones, delayed growth and development, leg ulcers, stroke and premature death. Three major sickle cell complications during the first years of life are dactylitis, splenic hypofunction and splenic sequestration. The risk for pneumococcal meningitis is 36 times greater in children with sickle cell anemia than for black children without the disease, and 314 times greater than for white children. [References: 15]

152.    Paul, L. (1998). The envelope please. 1997 HITS (Healthcare Innovations in Technology Systems) Partnership in Technology Award winners share the goals of improving patient care and improving outcomes. Healthcare Informatics, 15(6), 169-70-172.

153.    Padilla Leon, M., Marchal Escalona, C., Caballero Alcantara, J., Padilla LeonF. , & Lucas de Vega, I. M. (1998). [Shared care in BPH. First national experience]. [Spanish]. Actas Urologicas Espanolas, 22(6), 478-83; discussion 484.
Abstract: The high prevalence of Benign Prostate Hyperplasia and the increased demand for care of this condition, should compel us to plan for shared care models in parallel to Primary Care, in the way it has happened with entities such as HBP and Diabetes. The set of measurements to be adopted when sharing services with primary care is known as "shared care". This paper presents the first national experience of "shared care" with primary care in BPH. The project has consisted in a series of steps to increase awareness, train and make available for family physicians, a clinical practice guide defining the criteria for initial evaluation, medical treatment and referral of patients to Urology surgeries, including with the referral document the appropriate diagnostic tests. A Quality Commission has been created to study the level of compliance of the documentation used for referral to the specialist and the clinical histories of patients treated in primary care. The results obtained are significant and most studies carried out fulfill the requirements in 60% cases, which has allowed to reduce overcrowding in the Urology outpatient offices (4200 surgery visits saved/year in our environment), has provided easy access of patients to adequate diagnosis and treatment, as well as significant financial savings (30 million pesetas/year). In short "shared care" is a reality in our environment that allows a more effective, fast medical assistance and improved access to specialist care by reducing the demand of specialized surgery hours

154.    Moorhead, S., Clarke, M., Willits, M., & Tomsha, K. A. (1998). Nursing Outcomes Classification implementation projects across the care continuum. [Review] [6 refs]. Journal of Nursing Care Quality, 12(5), 52-63.
Abstract: The health care environment in which nurses deliver care is experiencing constant change characterized by decreased lengths of stay in acute care settings, increased use of technology, increasing emphasis on computerized patient records and care planning options, increasing markets dominated by managed care, and an emphasis on outcomes rather than process. These changes dictate that nursing as a profession ensures that the work of nursing is visible in this health care environment and included in the data used to make health policy decisions. This article describes the rich history of a Midwestern hospital's use of standardized nursing languages for the last 25 years. Currently this facility is in the process of implementing the Nursing Outcomes Classification (NOC). Four projects are described that illustrate the ways nurses can use this language with diagnoses from the North American Nursing Diagnoses Association (NANDA) and interventions from the Nursing Interventions Classification (NIC). [References: 6]

155.    Martin, G. I., Gattshall, K., MacPherson, F., & Tiffany, S. (1998). Future financial neonatal shock. [Review] [28 refs]. Pediatric Clinics of North America, 45(3), 619-34.
Abstract: In a changing economic climate, the neonatologist must be aware of all of the forces that can affect the practice of neonatology. In addition to clinical issues, billing and reimbursement must take into account physician work and common procedural terminology (CPT) codes, which accurately describe the medical services and procedures delivered. An understanding of this coding and resource-based work unit system is necessary to prevent financial loss. The influence of managed care, capitation, fixed per-case reimbursement, practice guidelines and care maps have already seriously affected clinical practice patterns. The neonatologist must be proactive in negotiating contracts using historic information and outcome data to define and defend the quality of care provided. [References: 28]

156.    London, M. J., Shroyer, A. L., Coll, J. R., MaWhinney, S., Fullerton, D. A., Hammermeister, K. E., & Grover, F. L. (1998). Early extubation following cardiac surgery in a veterans population [see comments]. Anesthesiology, 88(6), 1447-58.
Notes: Comment in: Anesthesiology 1998 Jun;88(6):1429-33
Abstract: BACKGROUND: Early tracheal extubation is an important component of the "fast track" cardiac surgery pathway. Factors associated with time to extubation in the Department of Veterans Affairs (DVA) population are unknown. The authors determined associations of preoperative risk and intraoperative clinical process variables with time to extubation in this population. METHODS: Three hundred four consecutive patients undergoing coronary artery bypass graft, valve surgery, or both on a fast track clinical pathway between October 1, 1993 and September 30, 1995 at a university-affiliated DVA medical center were studied retrospectively. After univariate screening of a battery of preoperative risk and intraoperative clinical process variables, stepwise logistic regression was used to determine associations with tracheal extubation < or = 10 h (early) or > 10 h (late) after surgery. Postoperative lengths of stay, complications, and 30-day and 6-month mortality rates were compared between the two groups. RESULTS: One hundred forty-six patients (48.3%) were extubated early; one patient required emergent reintubation (0.7%). Of the preoperative risk variables considered, only age (odds ratio, 1.80 per 10-yr increment) and preoperative intraaortic balloon pump (odds ratio, 7.88) were multivariately associated with time to extubation (model R) ("late" association is indicated by an odds ratio >1.00; "early" association is indicated by an odds ratio <1.00). Entry of these risk variables into a second regression model, followed by univariately significant intraoperative clinical process variables, yielded the following associations (model R-P): age (odds ratio, 1.86 per 10-yr increment), sufentanil dose (odds ratio, 1.54 per 1-microg/kg increment), major inotrope use (odds ratio, 5.73), platelet transfusion (odds ratio, 10.03), use of an arterial graft (odds ratio, 0.32), and fentanyl dose (odds ratio, 1.45 per 10-microg/kg increment). Time of arrival in the intensive care unit after surgery was also significant (odds ratio, 1.42 per 1-h increment). Intraoperative clinical process variables added significantly to model performance (P < 0.001 by the likelihood ratio test). CONCLUSIONS: In this population, early tracheal extubation was accomplished in 48% of patients. Intraoperative clinical process variables are important factors to be considered in the timing of postoperative extubation after fast track cardiac surgery

157.    Leininger, S. M., & Laux, L. H. (1998). The continuum of health care: highlights of orthopaedic and general medical pathways. Home Health Care Management & Practice, 10(4), 1-10.
Abstract: Clinical pathways have been developed and utilized to manage patients in the acute care setting. However, it is important to recognize and integrate the home setting whether it is a postoperative surgical patient or a patient with a chronic medical illness. This article will share two examples, one surgical and one medical, to demonstrate how home care agencies play an important role in the continuum of care. Copyright (c) 1998 by Aspen Publishers, Inc.  (5 ref)

158.    Lehman, L. B., Eagar, A., Saadi, H., & Bergren, R. (1998). Critical pathways: a program description in a national MCO. Managed Care Interface, 11(6), 54-6-63.

159.    Klein, A. S. (1998). A proposed clinical pathway for chiropractic management of chronic low back pain patients. Topics in Clinical Chiropractic, 5(2), 41-7, 60-72.
Abstract: Purpose: This article reviews information on chiropractic interventions for chronic low back pain and proposes a clinical pathway as a means for optimizing interventions. Method: The author performed a qualitative literature review. Summary: A clinical pathway for patients with chronic low back pain is proposed as a sample of the type of procedures that need to be established to treat clients. Copyright (c) 1998 by Aspen Publishers, Inc. All rights reserved  (69 ref)

160.   Holtzman, J., Bjerke, T., & Kane, R. (1998). The effects of clinical pathways for renal transplant on patient outcomes and length of stay. Medical Care, 36(6), 826-34.
Abstract: OBJECTIVES: Clinical pathways have been implemented nationwide but little is understood about their effects on efficiency of care and patient outcomes. The present study examined the effects of both development and implementation of two renal transplant pathways. METHODS: Cohorts of patients at a university hospital were compared before, during, and after the development and implementation of two renal transplant clinical pathways: isolated renal transplant from cadaveric donors (n = 170) or from living donors (n = 178). Clinical pathways for cadaveric and living related donor renal transplants were developed and implemented. Hospital length of stay and complications and infections after renal transplant were determined. RESULTS: Mean length of hospital stay decreased after development and implementation of the cadaveric donor pathway (11.8 days after implementation versus 17.5 days before development). Cadaveric kidney recipients also had statistically fewer complications and infections after both guideline development and guideline implementation (57.1% before, 24.5% during, 18.5% after), but the greatest effect occurred during development. All of these findings persisted after control for demographic and comorbid factors. There were no changes in hospital stay, complications, or infections in the patients who received kidneys from living donors. CONCLUSIONS: The development and use of a clinical pathway for cadaveric donor renal transplant patients was associated with a significant decline in length of stay, complications, and infections, but much of the effect was seen during development rather than during implementation, and a closely related pathway for living related donor patients had no effect. Further understanding of what factors predict an effective pathway and what elements (ie, development or implementation) have an effect should be undertaken

161.    Hohenleitner, S. G., & Minniti, M. J. (1998). Developing effective disease state management programs. Home Health Care Management & Practice, 10(4), 11-19.
Abstract: Disease state management programs, while still relatively new, are becoming a trend among home health care agencies. The article discusses components of a successful disease state management program, which include focusing on the entire population, addressing all phases of the disease, using well-designed clinical pathways, employing highly qualified and well-trained nurses, providing effective patient education, encouraging active participation by the patient, developing a positive relationship between the physician and nurse and between the nurse and case manager, and telephone intervention. The article also covers controversies about disease state management programs and how to address them. Copyright (c) 1998 by Aspen Publishers, Inc

162.    Hilliard, L. S. (1998). Manager's corner: innovative or disintegrate. Home Care Nurse News, 5(6), 1-2,8.

163.    Hajewski, C., Maupin, J. M., Rapp, D. A., Sitterding, M., & Pappas, J. (1998). Implementation and evaluation of Nursing Interventions Classification and Nursing Outcomes Classification in a patient education plan. Journal of Nursing Care Quality, 12(5), 30-40.
Abstract: Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) are recognized examples of standardized nursing languages used to describe the contribution nursing makes to patient care. Columbus Regional Hospital nursing leadership recognized the need to use standardized nursing interventions and nursing-sensitive patient outcomes to describe the unique contribution nursing makes to patient education. In collaboration with the University of Iowa, NIC/NOC languages were implemented in the development of a patient education plan for a clinical pathway population

164.    Gretebeck, R. J., Shaffer, D., & Bishop-Kurylo, D. (1998). Clinical pathways for family-oriented developmental care in the intensive care nursery. Journal of Perinatal & Neonatal Nursing, 12(1), 70-80.
Abstract: The physiologic and neurodevelopmental benefits of developmentally sensitive nursing care for high-risk infants have been well documented. The remaining challenge is to find ways to introduce developmental care principles into busy intensive care nurseries. The article discusses the development of three clinical pathways designed around five areas for developmental intervention: environmental organization, structuring of nursing care, feeding, family involvement, and family education. Each pathway incorporated developmental principles appropriate for a different level of care; the level III pathway was designed for acutely ill or very premature infants, the level II pathway for infants recovering from acute illness or older premature infants, and the level I pathway for full-term infants. Introduction of the developmental care pathways had an immediate positive impact in the tertiary level intensive care nursery at Allegheny General Hospital

165.    Brown, S. W., Griepp, A. Z., Buckley, S., James, A., & VanderMolen, N. (1998). Process-oriented critical pathways in inpatient psychiatry: our first year. Journal of Psychosocial Nursing & Mental Health Services, 36(6), 31-6.
Abstract: The critical pathway methodology of assigning and timing staff interventions and expected patient outcomes has developed worldwide recognition, but is less likely to be used in psychiatry than in other medical fields. At St. Mary's in Rochester, New York, an interdisciplinary team adapted the critical pathway concept to meet the needs of an acute inpatient population with relative success. Although staff education needs continue and plans to modify the pathway are in progress, all staff feel that the critical pathway is a viable tool for enhancing patient care and optimizing resources use. Benefits, obstacles, and suggestions are discussed

166.    Feinberg, B., & Feinberg, I. (1998). Overall survival of the medical oncologist: a new outcome measurement in cancer medicine. Cancer, 82(10 Suppl), 2047-56.
Abstract: BACKGROUND: Changing patterns of patient referral, decreasing payments for service provision, confusing network participation and reimbursement, as well as challenges to autonomous clinical decision-making jeopardize the traditional role of the oncologist in delivering cancer care. The cancer patient also may be at risk with unproven cancer delivery systems that displace the oncologist as decision-maker and care provider. The authors have constructed a model that preserves the oncologist's clinical and financial autonomy while meeting marketplace demands for improved access, decreasing costs and preserved quality of care. METHODS: During a 4-year period, a group of private practice medical oncologists initiated a formal business plan to evaluate marketplace needs, then designed and implemented a novel cancer care delivery model. The model required reconfiguring the practice into an integrated Joint Commission on Accreditation of Healthcare Organizations-certified cancer service corporation, providing medical, radiation, and gynecologic oncology. Palliative care, pain management, psychologic, and nutritional services were instituted as well as the vertical integration of home health and hospice care. Clinical pathways and treatment protocols were designed to enhance patient care and facilitate cost-of-care projections in designated populations using a cancer incidence forecasting model. Outcomes analysis are performed as part of ongoing continuous quality improvement, which continues to change this health care delivery system. RESULTS: In the 3 years since implementation of the model, the practice has increased from 16 to 24 physicians, and the number of offices has increased from 12 to 17. Patient encounters, both new and established, have doubled. Cost of services, specifically hospitalization, have been reduced by 50%. Clinical research referrals have increased 300%. Physician compensation has improved >20%. CONCLUSIONS: The model created a low cost, high value provider not burdened by allocated overhead. Decentralized care enhanced community access, which improved patient compliance, enhanced patient satisfaction, decreased hospitalization, and thereby decreased cost. The horizontal structure permited the flexibility for varied purchaser products and politically sensitive physician and hospital provider panels. Consensus-based protocol and pathway determination achieved maximum physician participation, which preserved clinical and financial autonomy, decreased variance, and facilitated clinical research

167.    Soumerai, S. B., McLaughlin, T. J., Gurwitz, J. H., Guadagnoli, E., Hauptman, P. J., Borbas, C., Morris, N., McLaughlin, B., Gao, X., Willison, D. J., Asinger, R., & Gobel, F. (1998). Effect of local medical opinion leaders on quality of care for acute myocardial infarction: a randomized controlled trial [see comments]. JAMA, 279(17), 1358-63.
Notes: Comment in: JAMA 1998 May 6;279(17):1392-4
Abstract: CONTEXT: The effectiveness of recruiting local medical opinion leaders to improve quality of care is poorly understood. OBJECTIVE: To evaluate a guideline-implementation intervention of clinician education by local opinion leaders and performance feedback to (1) increase use of lifesaving drugs (aspirin and thrombolytics in eligible elderly patients, beta-blockers in all eligible patients) for acute myocardial infarction (AMI), and (2) decrease use of a potentially harmful therapy (prophylactic lidocaine). DESIGN: Randomized controlled trial with hospital as the unit of randomization, intervention, and analysis. SETTING: Thirty-seven community hospitals in Minnesota. PATIENTS: All patients with AMI admitted to study hospitals over 10 months before (1992-1993, N=2409) or after (1995-1996, N=2938) the intervention. INTERVENTION: Using a validated survey, we identified opinion leaders at 20 experimental hospitals who influenced peers through small and large group discussions, informal consultations, and revisions of protocols and clinical pathways. They focused on (1) evidence (drug efficacy), (2) comparative performance, and (3) barriers to change. Control hospitals received mailed performance feedback. MAIN OUTCOME MEASURES: Hospital-specific changes before and after the intervention in the proportion of eligible patients receiving each study drug. RESULTS: Among experimental hospitals, the median change in the proportion of eligible elderly patients receiving aspirin was +0.13 (17% increase from 0.77 at baseline), compared with a change of -0.03 at control hospitals (P=.04). For beta-blockers, the respective changes were +0.31 (63% increase from 0.49 at baseline) vs +0.18 (30% increase from baseline) for controls (P=.02). Lidocaine use declined by about 50% in both groups. The intervention did not increase thrombolysis in the elderly (from 0.73 at baseline), but nearly two thirds of eligible nonrecipients were older than 85 years, had severe comorbidities, or presented after at least 6 hours. CONCLUSIONS: Working with opinion leaders and providing performance feedback can accelerate adoption of some beneficial AMI therapies (eg, aspirin, beta-blockers). Secular changes in knowledge and hospital protocols may extinguish outdated practices (eg, prophylactic lidocaine). However, it is more difficult to increase use of effective but riskier treatments (eg, thrombolysis) for frail elderly patients

168.    Sampson, B. K., & Doran, K. A. (1998). Health needs of coronary artery bypass graft surgery patients at discharge. Dimensions of Critical Care Nursing, 17(3), 158-64; quiz 165-8.
Abstract: Shortened hospital stays could potentially lead to unmet patient needs. This descriptive study utilizes critical pathway data and the Omaha System to identify the health needs of coronary artery bypass surgery patients at time of discharge. The most common health needs were education, sleep/rest and rehabilitation. Nursing implications relating to these health needs are also identified

169.    Quinn, K. (1998). Navigating critical pathway selection. Nursing Case Management, 3(3), 117-9.

170.    Nolan, M. T., Harris, A., Kufta, A., Opfer, N., & Turner, H. (1998). Preparing nurses for the acute care case manager role: educational needs identified by existing case managers. Journal of Continuing Education in Nursing, 29(3), 130-4, 142-143.
Abstract: BACKGROUND: There is little in the literature about how best to prepare nurses for case manager roles. METHOD: Twenty acute care case managers were asked to identify skills and knowledge that would be of value to nurses new to case manager roles. RESULTS: Community resources, discharge planning, and third party reimbursement were the top three educational needs identified by all case managers. Baccalaureate prepared case managers identified clinical issues to be of value, such as family coping, patient education, quality of life, and social support, while master's prepared nurses identified only system-related issues. CONCLUSION: Educational programs preparing baccalaureate prepared case managers could focus on both clinical and system issues, while programs preparing master's educated case managers could focus primarily on managing system issues. Staff development professionals may also call on experts inside and outside the institution to assist in teaching about health care finance and reimbursement issues.  (15 ref)

171.    Leininger, S. M. (1998). Publication excerpt. Building clinical pathways... this article is an a excerpt from the 40-page Building Clinical Pathways publication. Orthopaedic Nursing, 17(3), 75-77.

172.    Leininger, S. M. (1998). Building clinical pathways. Orthopaedic Nursing, 17(3), 75-7.
Abstract: TQM principles change the work environment so that point-of-service personnel can improve health care delivery to patients. The clinical pathway process starts with the principles of TQM. In the era of managed care, health care resources can be managed effectively using a clinical pathway. The multidisciplinary team has the opportunity to improve the health care services provided to patients

173.    Lagoe, R. J. (1998). Basic statistics for clinical pathway evaluation. [Review] [8 refs]. Nursing Economics, 16(3), 125-31.
Abstract: Clinical pathways (using accepted benchmark goals) are among the most widespread tools used to enhance outcomes and contain costs within a constrained length of stay (LOS). The author describes the need for selection and use of designated basic statistics in the "definition and evaluation of the impact of clinical pathways in hospitals." The use of both the mean and median data on resource use and LOS information (to evaluate the effectiveness of various clinical pathways) is advised, as the influence of outlier data will thus be revealed. The ultimate goal of such evaluation is the identification of statistics that can be readily "understood by and communicated among providers and consumers of health care services." The correlation of statistical variables such as resource utilization (including ICU stays) and LOS, can reveal patterns not easily seen otherwise. [References: 8]

174.    Brugh, L. A. (1998). Automated clinical pathways in the patient record legal implications. [Review] [13 refs]. Nursing Case Management, 3(3), 131-7.
Abstract: Nurses have long been taught the need for precise documentation of patient care. Yet, as demands on nurses' time increases, maintaining an accurate and informative patient record becomes more difficult. The use of an automated clinical pathway that contains both the plan of care and a record of the care, while increasing communication between the care providers, is a promising solution to the problem. In this article, the process of moving a clinical pathway from paper to a computerized format is discussed. Legal issues related to its status as a permanent part of the patient record are considered. The legal implications of the pathway as a standard of care are also examined. As clinical pathways and computers merge, effective automated plans of care that also can serve as a documentation tool will benefit both the caregiver and the patient, while decreasing the risk of liability. [References: 13]

175.    White, J. A. (1998). Managing care. Clinical pathways: who needs them? Physical Therapy Case Reports, 1(3), 162-4.

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

177.    Wexner, S. D. (1998). Standardized perioperative care protocols and reduced lengths of stay after colon surgery [editorial; comment]. Journal of the American College of Surgeons, 186(5), 589-93.
Notes: Comments: Comment on: J Am Coll Surg 1998 May;186(5):501-6

178.    Wammack, L., & Mabrey, J. D. (1998). Outcomes assessment of total hip and total knee arthroplasty: critical pathways, variance analysis, and continuous quality improvement [see comments]. Clinical Nurse Specialist, 12(3), 122-9; quiz 130-1.
Notes: Comment in: Clin Nurse Spec 1998 May;12(3):121
Abstract: Using critical pathways, with variance analysis and continuous quality improvement techniques to refine the pathways, the efficiency of total hip and total knee surgeries in one academic health center was maximized. Using a retrospective cohort study design, complications, readmissions, morbidity/mortality, and function scores were examined in two groups of patients attended by the same surgeon for the year before and the year after the implementation of an outcomes management program. The length of stay was reduced by 57% for knee patients and by 46% for hip patients. Hospital costs were reduced 11% for all knees and 38% for hips. Complications were also significantly reduced. There was no statistically significant difference between pre- or postoperative knee or hip outcome scores. The program resulted in significant savings without adversely affecting overall outcome

179.    Sullivan, J., Howland-Gradman, J., Schell, M., & Goldsmith, J. (1998). Reducing costs and improving processes for the interventional cardiology patient. [Review] [5 refs]. Critical Care Nursing Quarterly, 21(1), 68-82.
Abstract: The cardiology unit at the University of Chicago Hospitals developed a cost-saving mechanism in the care of postinterventional cardiology patients, reducing time spent in the coronary care unit. Increased nursing education and training and better identification of patient outcomes made this collaborative effort a cost-saving and effective pilot. [References: 5]

180.    Stegall, G. C. (1998). Blueprints: a critical pathway alternative. Hospital Case Management, 6(5), 95-8.

181.    Spath, P. (1998). Pathways can improve perioperative process. Hospital Case Management, 6(5), 90-4-99-100.
Abstract: With today's emphasis on horizontal and vertical integration of patient care services, caregivers are turning to clinical pathways to more effectively manage perioperative patients. Often, such pathways are generic (covering, for instance, all orthopedic or all vascular procedures). Such paths are especially helpful for organizations wishing to use the path for documentation purposes. In developing perioperative pathways, identify the specific patient care outcomes to be achieved; review patient records, nursing practice standards, and other materials to identify the common elements of care; and decide upon a process for reporting variances.  (Abstract by: Author)

182.    Spath, P. (1998). Guest column. Pathways can improve perioperative process: generic pathways help achieve integration of care. Hospital Case Management, 6(5), 90-94,99-100,108.

183.    Scarlett, M. V. (1998). Minimally invasive cardiac surgery: a new frontier. [Review] [18 refs]. Critical Care Nursing Quarterly, 21(1), 16-23.
Abstract: Modern cardiac surgery has been based on cardiopulmonary bypass, myocardial protection, aortic cross-clamping, and median sternotomy. Coronary artery bypass graft (CABG) has proven to be an effective treatment for patients who require surgical revascularization of the myocardium. Reports regarding the systemic effects of cardiopulmonary bypass abound in the literature. Such effects include hematologic, metabolic, pulmonary, cardiac, and cognitive dysfunction. Less invasive procedures have initiated a dramatic shift in treatment paradigms as well as reducing the cost of treatment. This article will discuss the MIDCAB--its history, a description of the surgical procedure, indications for use and patient selection, advantages and a perioperative plan including patient education and physical assessment. [References: 18]

184.    Ransom, S. B., McNeeley, S. G., Yono, A., Ettlie, J., & Dombrowski, M. P. (1998). The development and implementation of normal vaginal delivery clinical pathways in a large multihospital health system. American Journal of Managed Care, 4(5), 723-7.
Abstract: The entire country has become more concerned with healthcare costs due to managed care, capitation risk-based contracts, and the near elimination of the cost-plus reimbursement system. Clinical pathways have become one way to reduce unnecessary resource consumption by reducing provider variance, improving clinical outcomes, and reducing cost. We present here our rationale and process for developing a common clinical pathway for normal vaginal delivery in a large and varied multihospital system. We also discuss how this new pathway is expected to improve quality of care and reduce costs.  (Abstract by: Author)

185.    Morrison, S. A. (1998). Case in point. Clinical pathways for individuals with spinal cord injury... including commentary by Massery M. Physical Therapy Case Reports, 1(3), 129-39.
Abstract: BACKGROUND AND PURPOSE: Clinical pathways have been developed for many diagnoses. Owing to the uniqueness of outcomes for individuals who have sustained a spinal cord injury it has been thought that clinical pathways would not be beneficial for such a complex catastrophic injury. The purpose of this case report is to evaluate the usefulness of clinical pathways for the rehabilitation of an individual with spinal cord injury. PATIENT: The patient in this case report was a 33-year-old man who was paraplegic as a result of T7 level injuries sustained in a motor vehicle accident. INTERVENTION: This report is a retrospective look at the patient's rehabilitation program over the course of 4 weeks. His rehabilitation program was compared with the pre-established clinical pathway designed for individuals with paraplegia. OUTCOMES: The patient appeared to follow the clinical pathway with only a few variances from the expected functional outcomes. CONCLUSION AND DISCUSSION: The clinical pathway appeared to work well for this individual. The clinical pathway was beneficial in that it gave the physical therapists a blueprint of the essential components of care while leaving room for individualization. In addition, the clinical pathway saved documentation time, improved communication between the rehabilitation team members, and decreased time spent in team conference.  (5 ref)

186.    Macario, A., Horne, M., Goodman, S., Vitez, T., Dexter, F., Heinen, R., & Brown, B. (1998). The effect of a perioperative clinical pathway for knee replacement surgery on hospital costs. Anesthesia & Analgesia, 86(5), 978-84.
Abstract: Clinical pathways are being introduced by hospitals to reduce costs and control unnecessary variation in care. We studied 766 inpatients to measure the impact of a perioperative clinical pathway for patients undergoing knee replacement surgery on hospital costs. One hundred twenty patients underwent knee replacement surgery before the development of a perioperative clinical pathway, and 63 patients underwent knee replacement surgery after pathway implementation. As control groups, we contemporaneously studied 332 patients undergoing radical prostatectomy (no clinical pathway in place for these patients) and 251 patients undergoing hip replacement surgery without a clinical pathway (no clinical pathway and same surgeons as patients having knee replacement surgery). Total hospitalization costs (not charges), excluding professional fees, were computed for all patients. Mean (+/-SD) hospital costs for knee replacement surgery decreased from $21,709 +/- $5985 to $17,618 +/- $3152 after implementation of the clinical pathway. The percent decrease in hospitalization costs was 1.56-fold greater (95% confidence interval 1.02-2.28) in the knee replacement patients than in the radical prostatectomy patients and 2.02-fold greater (95% confidence interval 1.13-5.22) than in the hip replacement patients. If patient outcomes (e.g., patient satisfaction) remain constant with clinical pathways, clinical pathways may be a useful tool for incremental improvements in the cost of perioperative care. Implications: Doctors and nurses can proactively organize and record the elements of hospital care results in a clinical pathway, also known as "care pathways" or "critical pathways." We found that implementing a clinical pathway for patients undergoing knee replacement surgery reduced the hospitalization costs of this surgery

187.    Liao, S. L., Chu, S. H., Chen, Y. T., Chung, K. P., & Lai, M. K. (1998). The impact of a clinical pathway for transurethral resection of the prostate on costs and clinical outcomes. Journal of the Formosan Medical Association, 97(5), 345-50.
Abstract: The purpose of this study was to evaluate the effects of implementing a clinical pathway for transurethral resection of the prostate on hospital costs and procedures, outcomes, and complications. Consecutive patients who underwent transurethral resection of the prostate for benign prostate hyperplasia in our hospital before (February-August 1996) and after (October 1996-March 1997) implementation of the clinical pathway were included. Statistical analyses included Student's t-test to test the impact of the clinical pathway on resource consumption and medical care processes, and multiple linear regression to control for patient characteristics such as age, severity of disease, and comorbidity. The major findings of this study were that implementation of the clinical pathway 1) decreased resource consumption and controlled medical care expenditure; 2) influenced physicians' patterns of practice and decreased the number of procedures performed; and 3) did not affect clinical outcomes or complication rates. In conclusion, our results support the hypothesis that the clinical pathway is an effective medical management tool to contain costs, which does not adversely affect quality of care. We suggest health policy makers promote clinical pathways in more hospitals to encourage appropriate resource consumption

188.    Le, C. T., Winter, T. D., Boyd, K. J., Ackerson, L., & Hurley, L. B. (1998). Experience with a managed care approach to HIV infection: effectiveness of an interdisciplinary team. American Journal of Managed Care, 4(5), 647-57.
Abstract: To evaluate the function and effectiveness of a multidisciplinary team for managing human immunodeficiency virus (HIV) infection, we conducted a follow-up cohort study of HIV-positive patients managed according to a clinical care path at a staff-based health maintenance organization (HMO). The study group consisted of 230 HIV-positive health plan members who received care at the Kaiser Permanente Santa Rosa medical center (KPMC-SRO). In 1994, the comparison group consisted of 4747 HIV-positive health plan members who received care at Kaiser Permanente's 18 other medical centers in northern California. The percentages of acquired immunodeficiency syndrome (AIDS) and HIV-positive patients as determined by CD4+ T-cell counts were similar (P = 0.97). Compared with patients at the other Kaiser Permanente medical centers, KPMC-SRO patients had more visits with nurse practitioners (rate ratio [RR] = 1.72) and nutritionists (RR = 12.3) and fewer visits with primary care physicians (RR = 0.82). More HIV-positive members at KPMC-SRO received social workers' services (27% at KPMC-SRO vs 6% for patients at the other Kaiser Permanente medical centers) and fewer used emergency services (RR = 0.92) and psychiatric services (RR = .89). At KPMC-SRO, the mean number of days that AIDS patients spent in the hospital decreased from 7.8 (1991) to 2.01 (1994). Hospital admissions were fewer (AIDS patients, RR = 0.67; HIV-positive patients without AIDS, RR = 0.45), and length of stay was briefer, compared with patients at the other Kaiser Permanente Medical Centers. The mean cost of HIV-related drugs for patients seen at KPMC-SRO ($2343 per infected member) was lower than that for patients seen elsewhere in the region ($3289 per infected member). These results suggest that in an HMO setting, managed care provided by a dedicated interdisciplinary team according to a clinical care path can substantially and favorably affect resource use.  (Abstract by: Author)

189.    Huerta-Torres, V. (1998). Preparing patients for early discharge After CABG. American Journal of Nursing, 98 (5), 49-51.

190.    Huber, T. S., Carlton, L. M., Harward, T. R., Russin, M. M., Phillips, P. T., Nalli, B. J., Flynn, T. C., & Seeger, J. M. (1998). Impact of a clinical pathway for elective infrarenal aortic reconstructions. Annals of Surgery, 227(5), 691-9; discussion 699-701.
Abstract: OBJECTIVE: To determine the impact of a clinical pathway for elective infrarenal aortic reconstruction on outcome, resource utilization, and cost in a university medical center. SUMMARY BACKGROUND DATA: Clinical pathways have been reported to control costs, reduce resource utilization, and maintain or improve the quality of patient care, although their use during elective aortic reconstructions remains unresolved. METHODS: A clinical pathway was developed for elective infrarenal aortic reconstructions by a multidisciplinary group comprised of representatives from each involved service. The prepathway practice and costs were analyzed and an efficient, cost-effective practice with specific outcome measures was defined. The impact of the pathway was determined by retrospective comparison of outcome, resource utilization, and cost (total and direct variable) between the pathway patients (PATH, n = 45) and a prepathway control group (PRE, n = 20). RESULTS: There were no significant differences in the patient demographics, comorbid conditions, operative indications, or type of reconstruction between the groups. There were no operative deaths and the overall complication rate (PRE, 35% vs. PATH, 34%) was similar. The pathway resulted in significant decreases in the total length of stay and preoperative length of stay and a trend toward a significant decrease (p = 0.08) in the intensive care length of stay for the admission during which the operation was performed. The pathway also resulted in significant decreases in both direct variable and total hospital costs for this admission, as well as a significant decrease in the overall direct variable and total hospital costs for the operative admission and the preoperative evaluation (< or =30 days before operative admission). Despite these reductions, the discharge disposition, 30-day readmissions, and number of postoperative clinic visits within 90 days of discharge were not different. CONCLUSIONS: Implementation of a clinical pathway for elective infrarenal aortic reconstructions dramatically decreased resource utilization and hospital costs without affecting the quality of patient care and did not appear to shift the costs to another setting

191.    Goldberg, R., Chan, L., Haley, P., Harmata-Booth, J., & Bass, G. (1998). Critical pathway for the emergency department management of acute asthma: effect on resource utilization. Annals of Emergency Medicine, 31(5), 562-7.
Abstract: STUDY OBJECTIVE: To determine the effect of a critical pathway on resource utilization in asthmatic patients. METHODS: The study combined a prospective analysis of 149 patients with asthma treated by a pathway protocol with a retrospective analysis of 97 patients with asthma treated by conventional means. The setting was a community hospital. RESULTS: Among patients treated by protocol, oxygen use declined by 19% (P = .001), handheld nebulizer treatments by 33% (P = .001), saline locks by 15% (P = .011), and intravenous steroid administration by 13% (P = .034). There was an increase in the use of metered-dose inhalers with spacer by 64% (P = .001) and oral steroids by 18% (P = .027). CONCLUSION: A critical pathway, based primarily on national guidelines, can be an effective means of treating asthma patients in terms of resource utilization

192.    Dunbar, S. B., Jacobson, L. H., & Deaton, C. (1998). Heart failure: strategies to enhance patient self-management. [Review] [30 refs]. AACN Clinical Issues, 9(2), 244-56.
Abstract: Successful management of heart failure requires an active partnership between the patient and health care providers. This can be facilitated through a focused patient education plan that begins in acute care and has continuity into the community. Elements of the education plan involve both teaching content areas and self-management behaviors. Clinical pathways for heart failure incorporate teaching and educational strategies to guide the work of the multidisciplinary team, and the advanced practice nurse has tremendous potential in facilitating improved patient outcomes. [References: 30]

193.    Cahalin, L. P. (1998). Exercise training in heart failure: inpatient and outpatient considerations. [Review] [90 refs].  AACN Clinical Issues, 9(2), 225-43.
Abstract: Exercise training has become increasingly important in the treatment of heart failure patients. It has long been known that the exercise tolerance of a patient with heart failure is related to his or her morbidity and mortality. Recently, it has been proved that exercise training improves cardiorespiratory function, functional status, and psychosocial status of heart failure patients. It is unknown whether these improvements will improve morbidity and mortality but quality of life appears to be enhanced. Subtle improvements in these areas may lead to a more satisfying and productive life for many heart failure patients. However, further investigation of the specific effects of such improvements is needed. [References: 90]

194.    Bradshaw, B. G., Liu, S. S., & Thirlby, R. C. (1998). Standardized perioperative care protocols and reduced length of stay after colon surgery [see comments]. Journal of the American College of Surgeons, 186(5), 501-6.
Notes: Comment in: J Am Coll Surg 1998 May;186(5):589-93
Abstract: BACKGROUND: Recent studies have suggested that critical pathways and standard order sets decrease hospital length of stay and improve quality of care. A recently conducted prospective, randomized study at our institution found that patients undergoing elective colon resections had earlier return of bowel function if perioperative epidural anesthesia and analgesia were provided. All patients in the study were also placed on a standardized perioperative regimen. We hypothesized that the standardized perioperative protocol used in this study contributed to early return of bowel function and hospital discharge compared with similar patients managed off protocol. STUDY DESIGN: To test this hypothesis, we performed a case-controlled study comparing the hospital courses of 36 study patients to 36 control patients undergoing colorectal surgery by the same surgeons during the same calendar year. The distribution of types of operations and anesthetic techniques was similar in both groups. RESULTS: As dictated by the protocol, all study patients had their nasogastric tubes removed, were started on a low fat liquid diet, and ambulated in the first postoperative day. Nasogastric tubes were removed in control patients and study patients 2.2 +/- 0.9 (mean value +/- SD) and 1.0 +/- 0.0 days postoperatively, respectively. Control patients were started on an oral diet, usually clear liquids, an average of 2.9 +/- 1.1 days postoperatively, a specific liquid diet was started 1.0 day postoperatively in study patients (p < 0.001). Return of bowel function, as determined by bowel tones, flatus, and bowel movements, occurred approximately 1 day earlier in study patients. Study patients were discharged 1 day sooner than control patients. CONCLUSIONS: Our results suggest that the return of bowel function and the length of stay of patients undergoing colon surgery are improved if patients are entered into a standardized protocol that eliminates variation in intraoperative and postoperative anesthesia and postoperative surgical care. We believe these results can be reproduced in routine clinical surgery by having a clearly outlined protocol for perioperative care similar to that used in this study

195.    Currie, L., & Harvey, G. (1998). Care pathways development and implementation. [Review] [34 refs]. Nursing Standard, 12(30), 35-8.
Abstract: Care pathways are increasingly being used in the UK as a tool for managing clinical processes and patient outcomes. This article describes some of the key elements of care pathways, highlights factors in successful implementation and discusses some concerns about their use. [References: 34]

196.    Rospopa, J. (1998). The care programme approach. Nursing Times, 94(13), 55-7.

197.    Quigley, P. A., Smith, S. W., & Strugar, J. (1998). Successful experienced with clinical pathways in rehabilitation. Journal of Rehabilitation, 64(2), 29-32.
Abstract: Rehabilitation professionals from the Veterans Affairs Hospital (VAH) in Tampa, Florida, have four years of experience developing, utilizing and revising clinical pathways specific to most frequent rehabilitation admission diagnoses (such as strokes, traumatic brain injury, and pain diagnoses) of clients requiring comprehensive inpatient rehabilitation. The preparation, framework, and experiences of rehabilitation professionals using clinical pathways as the core method of operation are presented in this article. In addition, this article describes the interdisciplinary process utilized to develop and implement the clinical pathways for stroke and traumatic brain injury patients, and discusses the outcomes experienced by rehabilitation professionals. These clinical pathways focus on outcomes rather than process. Outcome measures are specific to program evaluation outcomes and include access to programs, functional status gains, length of stay, and length of stay efficiency. This article challenges readers to question clinical pathways that specify processes rather than outcomes, and argues the benefit of outcome-specific clinical pathways for use in rehabilitation settings.  (10 ref)

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

199.   Fleschler, R., & Luquire, R. (1998). Advanced practice role of the outcomes manager. Outcomes Management for Nursing Practice, 2(2), 54-6.

200.    Brown, S. W., & Nameth, L. S. (1998). Questions to ask: implementing a system for clinical pathway variance analysis. [Review] [26 refs]. Outcomes Management for Nursing Practice, 2(2), 57-62; quiz 62-3.
Abstract: Although it is agreed that there is a need for clinical pathway variance analysis, methods for creating a system are less well defined. To help others down this path, we have developed a list of questions around four core issues: data collection, data entry and analysis, data reporting, and organizational support. Our goal is to identify key questions related to variance management and provide a framework for clinical pathway variance analysis. [References: 26]

201.    Wright, S. (1998). Preparation for peripheral blood progenitor cell collection. Oncology Nursing Forum, 25(3), 471.

202.    Williams, L. D. (1998). Open heart surgery pathway package facilitates UR. Hospital Case Management, 6(4), 73-6.

203.    Wagner, L. (1998). Mapping out care. Pressure ulcer prevention and treatment path. Provider, 24(4), 32-42.

204.    Tucci, R. A., & Bartels, K. L. (1998). Ovarian cancer surgery: a clinical pathway. Clinical Journal of Oncology Nursing, 2(2), 65-6.
Abstract: Clinical pathways are useful tools in providing quality care while decreasing the cost of that care. Pathways help to facilitate managed care, identify patient and family educational needs, encourage multidisciplinary communication, and expedite patient discharge. This article discusses a clinical pathway for ovarian cancer surgery.  (1 ref)

205.    Tolman-Jager, A., & Banks, T. (1998). Better control of nausea and vomiting in transplant recipients. Oncology Nursing Forum, 25(3), 472.

206.    Rossiter, D. A., Edmondson, A., al-Shahi, R., & Thompson, A. J. (1998). Integrated care pathways in multiple sclerosis rehabilitation: completing the audit cycle. Multiple Sclerosis, 4(2), 85-9.
Abstract: The rehabilitation of progressive neurological disorders, such as Multiple Sclerosis (MS) requires comprehensive, expert management which is demanding of both time and resources. Mechanisms to monitor and audit both process and outcome are therefore essential. Integrated care pathways (ICPs) which detail the expected interventions during a given episode of clinical care, provide such a mechanism. In this study three cohorts of patients (totalling 125 episodes) with clinically definite progressive MS underwent a rehabilitation programme audited through ICPs. The cohorts were similar in relation to disability and age. Variations (departures from the expected pathway) were documented for both the rehabilitation process and goal achievement. Duration of stay reduced from 28 days for the first cohort to 18 days for the third and there was greater multidisciplinary input and carer involvement over time. Goal achievement increased from 79% for the first cohort to 87% for the third and there was an increased emphasis on cognitive function and fatigue management in relation to goals set. ICPs provide an excellent mechanism for closing the audit loop and have the potential to play an important role in improving service provision in MS

207.    O'Dell, C., Lightstone, L., Maloney-Lutz, K., Clements, P., Mancini, A., Moshe, S. L., & Shinnar, S. (1998). Issues related to caring for infants to adults on an integrated epilepsy unit. Journal of Neuroscience Nursing, 30(2), 124-8.
Abstract: We integrated the care of patients of all ages (ranging thus far from 4 weeks to 73 years) in our dedicated 8-bed Epilepsy Unit. Administrative issues pertaining to admission and discharge criteria, unit policies and procedures and an interdisciplinary quality assurance plan were examined in relation to the impact of combining both pediatric and adult patients. Clinical considerations included the diversified abilities needed to care for pediatric and adult patients both in relation to the technical skills as well as psychosocial skills required. The advantages of integrating patients of all ages on one unit include having a staff highly trained in assessment and intervention skills for a particular disorder. The psychosocial issues that arise in these patients, regardless of age, tend to encompass the entire family; therefore a holistic approach is appropriate for both children and adults. An autonomous nursing practice was established with the development of critical pathways and patient care protocols. Our experience suggests that integrated specialized units can enhance the care of patients with intractable seizures

208.    Michelman, M. S., & Babka, J. C. (1998). Quick results: clinical process improvement. Journal of the Florida Medical Association, 85(1), 12-5.

209.    Healy, W. L., Ayers, M. E., Iorio, R., Patch, D. A., Appleby, D., & Pfeifer, B. A. (1998). Impact of a clinical pathway and implant standardization on total hip arthroplasty: a clinical and economic study of short-term patient outcome. Journal of Arthroplasty, 13(3), 266-76.
Abstract: This study evaluates the impact of a clinical pathway (CP) and a hip implant standardization program (HISP) on the quality and cost of total hip arthroplasty (THA). Two hundred six unilateral THA operations for osteoarthritis were evaluated: 89 operations were performed in 1991 without a CP or HISP (4-year follow-up period); 117 operations were performed in 1993 with a CP and HISP (2-year follow-up period). All patients had good clinical results and excellent outcomes with short-term follow-up evaluation. No differences were seen between groups in terms of patient ratings of outcome and satisfaction or in terms of complication rates in the hospital. Implementation of a CP and HISP did not adversely affect the short-term outcome of THA but did reduce hospital length of stay and hospital cost for THA

210.    Dozier, A. M. (1998). Professional standards: linking care, competence, and quality. Journal of Nursing Care Quality, 12(4), 22-9.
Abstract: Professional standards are key to the success of nurses as health care evolves, new roles are created, and new practice settings established. They are the infrastructure beneath the development of institutional standards of care, competency-based education programs, and quality assurance programs. Using them to link these key components provides for consistency across practice settings and among practicing nurses within integrated delivery systems. They also serve as the foundation for consensus building for partnerships and interdisciplinary initiatives

211.    Casey, K., Bedker, D. L., & Roussel-McElmeel, P. L. (1998). Myocardial infarction: review of clinical trials and treatment strategies. [Review] [57 refs]. Critical Care Nurse, 18(2), 39-52; quiz 53-4.

212.    Riley, K. (1998). Care pathways. Paving the way. Health Service Journal, 108(5597), 30-1.
Abstract: Care pathways are most commonly used in acute trusts and private hospitals, according to a survey by the National Pathway Association. Orthopaedics is the specialty most likely to employ pathways, followed by surgery, medicine and care of elderly people. A third of respondents found the tool helped control costs, but a similar number found it did not. Setting and implementing standards of care and improving communication between staff are the most commonly reported benefits of using care pathways.  (Abstract by: Author)

213.    Kidorf, M., Hollander, J. R., King, V. L., & Brooner, R. K. (1998). Increasing employment of opioid dependent outpatients: an intensive behavioral intervention. Drug & Alcohol Dependence, 50(1), 73-80.
Abstract: The impact of a new, mandatory employment requirement in a community-based methadone treatment program was evaluated. All patients who had been in the methadone substitution program for at least 1 year but who were not currently employed (n = 36) were required to enhance their treatment with 20 h of employment (paid or volunteer). Patients with significant psychiatric or medical disabilities were excluded from the routine treatment requirement. Patients were informed by counseling staff that they had 2 months to secure employment. Those who did not accomplish the goal within that time period were transferred to more intensive weekly counseling (i.e. up to 8 h/week) for 10 weeks, with the enhanced counseling focusing primarily on resistance to the employment goal. Patients who remained resistant to the treatment plan were eventually started on a 21 day methadone taper until employment was verified. Seventy-five percent of the patients secured employment and maintained the position for at least 1 month. Positions were found in an average of 60 days. Most patients (78%) continued working throughout the 6-month follow-up. Those who failed to find work or maintain employment engaged in more illicit drug use. These results demonstrate that behavioral contingencies can motivate many methadone maintenance patients to obtain verified employment in the community

214.    Underwood, F., & Parker, J. (1998-1999). Developing and evaluating an acute stroke care pathway through action research. Nurse Researcher, 6(2), 27-38.
Abstract: Here the authors describe how action research was integral to changing practice when a care pathway was introduced for patients following a stroke.  (17 ref)

215.   Walters, J. (1998). Home care critical pathways for coronary artery bypass graft clients. Progress in Cardiovascular Nursing, 13(2), 34-6.

216.    Cyr, J. J., & Peppler, C. (1998). A comprehensive community-based model of psychogeriatric care. Perspectives, 22(1), 11-6.

217.    Whittington, C. F. (1998). Outcomes management: who, what, where, why, how. [Review] [32 refs]. Orthopaedic Nursing, 17(2 Suppl), 15-9.

218.    Tahan, H. A. (1998). Case management: a heritage more than a century old. Nursing Case Management, 3(2), 55-60; quiz 61-2.
Abstract: The roots of case management are more than a century deep. This innovative approach to managing, coordinating, expediting, and facilitating patient care is neither new nor exclusively limited to nursing practice. A review of the historic literature reveals that the evolution of case management is a byproduct of creative healthcare efforts associated with different disciplines, including nursing, medicine, mental health, public health, and social work. This article presents a historical review of significant milestones in the evolution of the field of case management and its related tools (i.e., clinical pathways)

219.    Stanfill, P. H., Weber, D. G., & Wayne, C. (1998). Clinical patient information capture: the Columbia/HCA cancer care database experience. Journal of Oncology Management, 7(2), 17-21.
Abstract: Development of a cancer care database and interpretation of its contents will provide extensive information about a set of patients with a particular disease. By defining disease by stage, its associated costs of diagnosis, treatment and long term follow-up, patient outcomes and self-reported satisfaction and quality of life, a foundation for disease management evolves. Utilizing documented experience over the continuum of cancer care provides a stronger foundation for standards of care and critical pathway development as well as enhancing risk sharing capabilities in providing care for a set of cancer patients. Extensive data collection and analysis has been identified as the key to successful disease management. With the Columbia/HCA Cancer Care Database and future strategic initiatives, the development of an oncology disease management approach is aggressively moving forward.  (Abstract by: Author)

220.    Smoot, S. M. (1998). Continuity of care prism process applied to the congestive heart failure population. Nursing Case Management, 3(2), 79-88.
Abstract: Emphasis in healthcare during the 1990s has been both to provide optimal wellness and function with quality in a cost-effective manner. The Continuity of Care Prism Process was developed to meet the need to guide clients along the continuum of care and to achieve continuity of care. Advanced practice nurses are the "expert" clinicians in a position to care manage clients and meet the financial and quality constraints currently being placed on healthcare agencies. In this article, the vehicle used to demonstrate the Continuity of Care Prism Process is a congestive heart failure clinical pathway

221.    Rieve, J. A. (1998). Guidelines & outcomes. Disease management concerns. Case Manager, 9(2), 34-36.

222.    Qamar, A., Bernstein, L. H., & Zarich, S. (1998). Outcomes research is the fifth discipline of the fifth generation of managed care: utility of a single troponin-T. Clinical Laboratory Management Review, 12(2), 80-6.
Abstract: OBJECTIVE: The fifth generation of managed care is disease management. Diseases have measurable risk in providing laboratory and medical services. The link between managing services and managing risk can be aided by leveraging the laboratory. We wish to remodel laboratory services to fit the needs of the use, thereby using the laboratory for competitive advantage by redesigning a desired output using a formal structured process. Outcomes research is the systems framework for the remodeling process through the link of laboratory output to clinical and financial outcomes. A process redesign model connects the use of laboratory tests to improved medical services by leveraging resources to achieve measurable improvement over current results. This view of outcomes research seeks both competitive advantage and measurable improvements in quality. METHODOLOGY: This approach is illustrated by the patient presenting with chest pain (CP). A majority of the patients rule out for acute myocardial infarction (AMI), including patients with indigestion, shortness of breath, and other clinical findings. This is the basis for an emergency department (ED) CP observation unit to reduce coronary care unit admission rates. When the Goldman algorithm for discharging low-risk patients with CP from the ED using only clinical features and electrocardiographic findings proved difficult to implement, we turned to measuring the diagnostic efficiency of a new cardiac marker to replace the evolutionary changes in creatine kinase (CK) isoenzyme MB. The physicians making the decision were blinded to the results of the study. We fitted the expected characteristics of the test to the expected results for our program. The test was done on the presenting specimen of 293 evaluable patients with a median of 6.5 hours from the time of onset of CP to the time the specimen was drawn. The result was compared with the evolutionary pattern of CK-MB. RESULTS: The sensitivity of the test at presentation to the ED was 85% compared with < 50% for the presenting CK-MB, the false negative results taken earlier than 3 hours or 10 days after the onset of symptoms. Troponin-T effectively identifies non Q-wave AMI much earlier than the CK-MB. This study led to a prospective randomized clinical trial to demonstrate an improved medical and financial benefit from an early rule in or rule out of severe coronary artery ischemia. CONCLUSION: The study supports our hypothesis that the laboratory can systematically redesign its technology strategy and participate in the construction of a clinical pathway for the discharge from ED or admitting decisions with a test 98% sensitive for identifying patients with serious coronary ischemia by 3.5 hours after the onset of symptoms.  (Abstract by: Author)

223.    Messer, B. (1998). Reducing lengths of stays in the total joint replacement population. Orthopaedic Nursing, 17(2 Suppl), 23-5.

224.    Mabe, P. R., & Lengacher, C. A. (1998). Redesigning emergency care: financial and cost analysis of services provided. Nursing Economics, 16(2), 75-82.
Abstract: Developing an interdiscliplinary team to monitor and implement redesign is critical to successful, quality outcomes. Analysis of the current status of the organization and national trends is essential prior to redesign. Key assessment data gathered were: profiling users, payer distribution, inpatient admissions, data on types of chronic conditions, DRGs, readmits, short-stay admissions, non-admits, and outpatient services and charges. Organizational realignment requires time and analysis of financial, clinical, and demographic data. The team-building framework used in this emergency room redesign was based on a collaborative model. A crucial initial step was to get support from the organization's executive level of leadership for the new redesign vision. Another factor considered essential for a successful outcome was commitment from each member of the interdisciplinary team. Communication between the team and staff was a top priority

225.    Doan-Johnson, S. (1998). The growing influence of wound care teams [editorial]. Advances in Wound Care, 11(2), 54.

226.    Coto, J. A. (1998). Pediatric lower airway disease: do not be blown away by cost. Nursing Case Management, 3 (2), 75-8.

227.    Bower, K. (1998). Case management: unraveling the confusion. Orthopaedic Nursing, (Suppl), 7-14.

228.    Ariagno, R. L. (1998). Who is responsible for making medical decisions? [editorial]. Journal of Perinatology, 18(2), 89-90.

229.    Zander, K. (1998). Historical development of outcomes-based care delivery. [Review] [29 refs]. Critical Care Nursing Clinics of North America, 10(1), 1-11.
Abstract: Outcomes-based care delivery is both a subtle and profound change in practice. It is proactive, patient-centered, data-generating, and establishes clear accountability. Most importantly, outcomes defined and managed at the patient-provider level will be the quality conscience as health care enters a new millennium. [References: 29]

230.    Walters, J., Schwartz, C. F., Monaghan, H., Watts, J., Shlafer, G. J., Deeb, G. M., & Bolling, S. F. (1998). Long-term outcome following case management after coronary artery bypass surgery. Journal of Cardiac Surgery, 13(2), 123-8.
Abstract: Patient outcome following coronary artery bypass grafting (CABG) has come under increasing governmental, social, and economic scrutiny. To insure quality patient outcome after CABG, many new policies and programs have been instituted. One of these, case management, was developed as a tool for identification and quantification of patient clinical sequences and resource utilization. This present study examines the influence of case management on length of stay and patient outcome following CABG. One hundred forty randomized, retrospectively analyzed CABG patients from 1990, prior to case management, were compared against 140 age-and case-matched randomly controlled CABG patients from 1994 after case management was in place. Patients' demographics were similar. The outcome data showed that intensive care unit (ICU) use and total length of stay were significantly decreased. Furthermore, resource utilization as monitored by chest X-ray, electrocardiography, and laboratory testing were decreased as well. Finally, mortality was decreased despite an increase in risk-adjusted acuity of the patients. There appeared to be no effect of gender or age on the benefit derived from case management. These data demonstrate that the influence of case management is beneficial for resource utilization and patient outcome following CABG and that these types of patient care policy advancements should be encouraged

231.    Uzark, K., Frederick, C., Lamberti, J. J., Worthen, H. M., Ogino, M. T., Mainwaring, R. D., & Moore, J. W. (1998). Changing practice patterns for children with heart disease: a clinical pathway approach. American Journal of Critical Care, 7(2), 101-5.
Abstract: BACKGROUND: Pediatric cardiac care is costly and requires extensive resources. We studied the effect of clinical pathways on practice patterns and patient care outcomes in infants and children hospitalized for cardiac surgery. METHODS: In consecutive patients admitted for selected cardiac surgical procedures before (n = 69) and after (n = 173) implementation of clinical pathways, outcomes including hospital length of stay, days in the ICU, time to extubation, ordering of blood studies, costs, and readmissions were compared. Data were analyzed for each of five cardiac surgical procedures: repair of an atrial septal defect, repair of a ventricular septal defect, division of a patent ductus arteriosus, repair of tetralogy of Fallot, and neonatal arterial switch operation to correct transposition of the great arteries. RESULTS: A significant reduction in length of hospital stay, including days in the ICU (decreased 1 to 2 days per admission), was achieved after the clinical pathway was implemented. Reductions in average duration of mechanical ventilation ranged from 28% for repair of a ventricular septal defect to 63% for repair of tetralogy of Fallot. The number of blood studies ordered decreased 20% to 30%. A significant reduction in hospital costs for each procedure, ranging from 16% to 29%, was also achieved with no adverse effects on patients' outcomes. CONCLUSIONS: Use of clinical pathways with children hospitalized for cardiac surgery can shorten length of stay in the hospital, reduce use of resources, and improve cost-effectiveness with beneficial outcomes for patients.  (13 ref)

232.    Tovar, E. A., Roethe, R. A., Weissig, M. D., Lloyd, R. E., & Patel, G. R. (1998). One-day admission for lung lobectomy: an incidental result of a clinical pathway. Annals of Thoracic Surgery, 65(3), 803-6.
Abstract: BACKGROUND: Most complications after lung lobectomy are related to pain, narcotic analgesia, and inactivity. When the operation is performed with the goal of minimizing postoperative pain, and when rapid restoration of activity and patient independence can be achieved, most postoperative complications can be obviated and early discharge can be attained. METHODS: Since March 1996, we have performed 10 consecutive elective major lung resections (8 lobectomies and 2 bilobectomies) for neoplastic (n = 8) and benign inflammatory (n = 2) lesions. Of the 10 patients, 4 were men and 6 were women ranging in age from 58 to 77 years (mean age, 66 years). Extensive preoperative patient and family education was provided in the surgeon's office. Same-day admission was followed by an oblique muscle-sparing minithoracotomy to access the chest cavity. A meticulous operation, with special attention to minimizing air leak and postoperative discomfort, was performed. Intercostal nerve cryolysis was used as the main method of analgesia. RESULTS: All patients underwent the planned operation through a minithoracotomy and were extubated in the operating room. All patients exhibited normal ipsilateral shoulder girdle mobility in the recovery room and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation. The chest tube was removed the night of the operation in 2 patients, the morning after the operation in 6 patients, and on the second postoperative day in 1 patient. One patient who was discharged with a Heimlich valve had this device removed in the office 4 days after the operation. After the chest tubes were removed, there were no instances of pneumothorax. All 10 patients were able to ambulate independently on the first postoperative day. Eight patients were discharged home the morning after the operation and 2 on the second postoperative day. None of the patients have required readmission related to their operation or have exhibited evidence of postthoracotomy pain syndrome. CONCLUSIONS: We have developed a clinical pathway based on patient education, meticulous minimally invasive operation, cryoanalgesia, and quick resumption of physical activity. Our preliminary experience with this approach has shown minimal morbidity, rapid restoration to preoperative status, and, for most patients, a 1-day hospital stay after major lung resection

233.    Tobin, C. R., Sabatte, E., Sandhu, A. S., & Penafiel, E. (1998). A neonatal care map based on gestational age. Neonatal Network, 17(2), 41-51.
Abstract: Care maps have been used successfully in the adult population. To evaluate the use of these patient care models in the neonatal population, one Level III NICU compared data on 146 infants who ranged in gestational age from 24 to 33 weeks. Nine clinical benchmarks were identified as serving to define the infant's progress. These nine benchmarks were back to birth weight, extubation, discontinuation of hyperalimentation, discontinuation of NCPAP, feeding trial via orogastric tube, weaned to open crib, discontinuation of oxygen, full oral feedings, and discharge home. Gestational age was consistently observed to be the dominant determinant of the infant's readiness to achieve these physiologic tasks. The result of this project is a neonatal care map, based on gestational age. This care map outlines the expected treatment and response of the neonatal patient. It serves as a guide for both clinicians and families

234.    Rogers, M. A., & Cox, J. A. (1998). Laparoscopic paraesophageal hernia repair with Nissen fundoplication. AORN Journal, 67(3), 536-40, 542, 544-546 passim.
Abstract: Laparoscopic approach to paraesophageal hernia repair is a recent application of minimally invasive videoscopic surgery. Procedures such as paraesophageal hernia repair with Nissen fundoplication that previously could only be performed as open techniques now can be performed laparoscopically. Laparoscopic approach of this major surgical repair benefits patients because of the reduced surgical time, decreased length of hospital stay, reduced hospital costs, and a reduction in loss of work time

235.    Rogers, J. P., Novchich, T. M., Pearce, G. L., Johnston, J. S., Burton, H. G. 3rd, & Groh, M. A. (1998). Port-access cardiac surgery protocols and early outcomes. [Review] [38 refs]. Critical Care Nursing Clinics of North America, 10(1), 61-73.
Abstract: As a new cardiac surgical procedure, port-access holds promise to significantly impact the surgical approaches for treatment of CAD. Supporting collaborative practice protocols contributes to early extubation, rapid in-hospital recovery, and shortened LOS. Discharge protocols address postoperative concerns. Early results suggest that patient recovery is shorter than the time for conventional procedures; patients are able to return to an active lifestyle that is beneficial to families, patients, and employers. [References: 38]

236.    Rauck, R. L., Gargiulo, C. A., Ruoff, G. E., Schnitzer, T. J., & Trapp, R. G. (1998). Chronic low back pain: new perspectives and treatment guidelines for primary care: Part II. Managed Care Interface, 11(3), 71-5.
Abstract: Low back pain is a leading cause of work-related disability and has important socioeconomic consequences. Although there is little evidence to determine the optimal treatment of chronic low back pain, treatment goals can be established. Primary care providers should focus simultaneously on pain management, improvement of activity and functional level, and fostering a greater understanding of chronic low back pain. This two-part article summarizes consensus guidelines developed by practitioners with expertise in pain management, family medicine, internal medicine, physical therapy, rheumatology, and managed care and provides direction for primary care providers on a multidisciplinary approach to the patient with chronic low back pain. This part examines pharmacologic methods.  (Abstract by: Author)

237.    Propotnik, T. (1998). The clinical resource management model. Critical Care Nursing Clinics of North America, 10(1), 21-31.
Abstract: The clinical resource management model is a highly successful method of redesigning operations to focus on reducing costs while improving quality. In these dynamic days in our medical centers it is important to maintain quality standards while implementing cost reductions. Through careful analysis of our practice we can learn from our best practicing providers and build systems to replicate their example. By improving our processes of care we meet the expectation of the public and our regulators through process improvement in a collaborative, multidisciplinary manner

238.    Price, B. J., Bernard, G. R., Drew, K., Foss, J., & Wheeler, A. P. (1998). Impact of a critical care pathway for unstable mechanically ventilated patients. Critical Care Nursing Clinics of North America, 10(1), 75-85.

239.    Potter, D. (1998). Managed care: a view from Down Under. Nursing Management, 4(10), 11-3.

240.    Oiesvold, T., Sandlund, M., Hansson, L., Christiansen, L., Gostas, G., Lindhardt, A., Saarento, O., Sytema, S., & Zandren, T. (1998). Factors associated with referral to psychiatric care by general practitioners compared with self-referrals. Psychological Medicine, 28 (2), 427-36.
Abstract: BACKGROUND: The gatekeeper function of the general practitioner (GP) in the pathway to specialized psychiatric services was investigated in this study, which is part of the Nordic Comparative Study on Sectorized Psychiatry. The question addressed in this paper is whether different sociodemographic and clinical factors as well as factors related to service utilization are associated with referral from the GP compared with self-referrals (including referrals from relatives). METHODS: The study comprised a total of 1413 consecutive patients, admitted during 1 year to five psychiatric centres in four Nordic countries. The centres included in this study were those that accepted non-medical referrals. Only new patients (not in contact with the service for at least 18 months) were included. RESULTS: Increasing age was the only sociodemographic factor significantly associated with referral by the GP. The clinical factors (psychosis, being totally new to psychiatry and being in need of in-patient treatment) and some treatment characteristics (planned out-patient treatment and involuntary in-patient treatment), were all significantly associated with referral by the GP. Some indication was found that self-referred patients have shorter episodes of care. CONCLUSIONS: The findings were remarkably stable across the different centres indicating a general pattern. This study extends previous work on the role of GPs in the pathway to specialized psychiatric services and indicates that the GP has an important gatekeeper function for the most disabled patients

241.    Kirk, A., & Thompson, J. (1998). Practical pathways: a multidisciplinary approach to asthma. Paediatric Nursing, 10(2), 18-20.

242.    Jones, A., & Kamath, P. D. (1998). Issues for the development of care pathways in mental health services. Journal of Nursing Management, 6(2), 87-95.
Abstract: AIMS: This paper seeks to discuss some of the issues for the development of care pathways for inpatients with schizophrenia. BACKGROUND: Managed care pathways are becoming increasingly popular for general adult conditions. Little is known about the development or application of care pathways for mental health services, and in particular, for inpatients diagnosed with schizophrenia. METHODS: Action research principles were adopted to engage and develop support to examine care pathways. Participant observation and unstructured interviews were the primary methods used during this phase of the research. The paper draws on the experiences of one of the authors (AJ) and his attempt to discuss the potential development of a care pathway for in-patients with schizophrenia in one inner city locality in London. FINDINGS: Four central issues were identified by the group; individualized care versus standardized care, generic practice and generic education. CONCLUSIONS: The development and application of care pathways for mental health services requires the consent and commitment from the work force. Many crucial barriers to development arose during the discussion groups and these will require further attention by prospective organizations wishing to apply care pathways to complex diagnostic groups such as schizophrenia

243.    Hickman, J. L. (1998). Outcomes management for stroke patients using thrombolytics. [Review] [26 refs]. Critical Care Nursing Clinics of North America, 10(1), 101-15.
Abstract: In the current health care market, there is a sharp awareness by both consumers and managed care providers that hospitals are only as good as the outcomes they can produce. Collaboration among disciplines that provide services, in this case treatment for stroke has enhanced patient outcomes. The synergy that has developed among those involved has thus far created a win-win situation. The key to successful outcomes is to have all those involved possessing a clear picture of their role, accepting it, and taking ownership of it. [References: 26]

244.    Dixon, A. (1998). Partnership and managed care: a way forward... this paper is an edited version of a keynote address given at the Australasian Nurse Educators' conference in Christchurch, New Zealand, October 1997. Nursing Praxis in New Zealand, 13(1), 4-11.
Abstract: As the programme of health reform in New Zealand gains momentum the number of new concepts and terms used to describe them is increasing to an extent where it would be easy for nurses, on whom the changes have major impact, to become overwhelmed. Most prominent and influential among the current ideas are managed care, evidence based practice, critical pathways and cultural safety. All these are permeated by the change process. In this paper critical issues surrounding aforementioned terms are discussed from both a professional and a consumer viewpoint, with reference to both the literature and media sources. The purpose is clarification, with the aim of assisting nurses to be more engaged in the debate.  (19 ref)

245.    Coombs, V. J. (1998). Outcomes management for interventional cardiology. [Review] [21 refs]. Critical Care Nursing Clinics of North America, 10(1), 53-9.
Abstract: In the evolution of quality assessment activities in interventional cardiology, outcomes management has become the benchmark for demonstrating optimal care. The high volume of interventional cardiology procedures performed each year mandates that efficient, high-quality and cost-effective patient care be delivered to all patients with cardiovascular disease. Although the interventional cardiology procedures represent only a snap shot of the patient's management of coronary artery disease, a long-term plan for positive outcomes is required. A multidisciplinary approach to outcomes management facilitates institutions to be competitive in today's health care market. [References: 21]

246.    Chang, P. L., Huang, S. T., Wang, T. M., Hsieh, M. L., & Tsui, K. H. (1998). Improvements in the efficiency of care after implementing a clinical-care pathway for transurethral prostatectomy. British Journal of Urology, 81(3), 394-7.
Abstract: OBJECTIVE: To investigate the efficiency of care, length of hospital stay and admission charges after implementing a clinical-care pathway for transurethral prostatectomy (TURP). PATIENTS AND METHODS: Changes in the length of hospital stay and admission charges were identified by comparing a series of 100 patients undergoing TURP and treated after implementing a clinical-care pathway with 100 patients treated by the same physicians before implementation. RESULTS: After implementing the care pathway, the mean length of hospital stay and admission charges were significantly lower (P < 0.01). The shorter length of stay was caused by a significant reduction (P < 0.05) in patient-related psychological/social delay after implementation. The number of laboratory tests and use of pharmacological agents were also significantly lower (P < 0.001) after implementation, with the decreases in these last variables significantly greater (P < 0.001) among junior physicians. CONCLUSIONS: The advantages of the TURP clinical-care pathway were the shorter hospital stay, arising from reduced patient-related psychological or social delay, and reduced admission charges consequent on the decreased use of laboratory tests and drugs, particularly for patients treated by junior physicians. These results suggest that physicians are likely to modify their management methods to improve efficiency when a clinical path is implemented

247.    Burns, S. M. (1998). The long-term mechanically ventilated patient. An outcomes management approach. [Review] [34 refs]. Critical Care Nursing Clinics of North America, 10(1), 87-99.
Abstract: As noted previously, prior to permanently instituting an outcomes approach, we compared the effects of such a model to a nonoutcomes-managed approach. The positive trend noted during the study interval has been sustained 2 years later, and the variables of cost, LOS, and ventilator duration (median = 9 days for DRG 475, 483 combined) for these patients continue to be favorably affected (see Figure 2). In addition, the outcomes-management model has been well accepted by all members of the health care team. The outcomes manager is a respected and valued member of the team and is central to the ongoing success of the approach. Although the clinical pathway is an essential tool for focusing and delineating multidisciplinary best-practice, the pathway (and processes of care contained within) must be continually evaluated and changed as needed. The pathway cannot be static if care is to be progressive. Essential to the process is a method of collecting and processing data in a timely way. Further, it is important that data collection, while important, not be the focus of the role of outcomes manager. Instead, the focus is the delivery of timely and effective care. Our current outcomes model applies to management of patients beyond the boundaries of the MICU or pulmonary suite. In other words, once weaned and transferred to a regular floor the outcomes manager no longer manages the patients (although she does track selected outcomes). Management of patients throughout hospitalization is a future goal, but we are convinced that this cannot be accomplished by a single outcomes manager. Although we are aware that other outcomes models do follow patients throughout the continuum of hospitalization and beyond, our highly clinically interactive model precludes that possibility. We are currently considering other similar unit-based positions to provide the desired continuity following discharge from the MICU or pulmonary suite. Despite our enthusiasm for the outcomes-management model, we recognize that other models may also result in comparable, favorable outcomes. It is important that those who adopt similar models of care delivery for managing patients requiring prolonged ventilation be scientific in their approach. Long-term studies of the efficacy of these models are essential if we are to truly provide quality care for our patients in the future. Unfortunately, as noted earlier, bias will be hard to overcome. Hospitals vested in rapidly establishing a stable financial bottom-line are likely to embrace quick applications. Projects with a true experimental design to evaluate efficacy, such as this one, will be rare in these organizations. Finally, it is critical that variables of interest be inclusive of specific quality indicators such as ventilator duration and complications rather than global institutional markers such as LOS. Standardization of variables of interest is imperative if outcomes are to be compared. For example, patients requiring long-term mechanical ventilation are identified by the AACN's Third National Study Group on weaning as those who require mechanical ventilation for more than 3 days. If we are to compare other variables of interest such as total ventilator duration, such as definition is essential or we will be comparing apples and oranges in the future. Provision of quality, cost-effective care for patients requiring prolonged ventilation is a true clinical challenge. Outcomes management is a multidisciplinary method of care delivery that is systematic and comprehensive in approach. Although little science exists related to the application of the model for patients requiring prolonged ventilation, preliminary reports are promising and warrant future applications and evaluation of the same. [References: 34]

248.    Bower, K. A. (1998). A career path in clinical pathways. Seminars for Nurse Managers, 6(1), 10-4.
Abstract: Much like the development of a clinical path, the creation of a career path requires knowledge of patterns of behavior, needs for standardized education and skill development, along with variance analysis and individualized care. This nationally known nursing entrepreneur tells the story of her involvement in the development of case management and clinical pathways and how she turned that into a successful business that has changed how patient care is managed nationally and internationally

249.    Bennet, R., & Morabito, J. (1998). Care path for the mentally ill/chemically addicted. Hospital Case Management, 6(3), 51-4.

250.    Zacharias, S., Rodriguez-Garcia, A., Honz, N., & Hooper, C. (1998). Development of an alcohol withdrawal clinical pathway: an interdisciplinary process. Journal of Nursing Care Quality, 12 (3), 9-18.
Abstract: Studies show that as many as 40 percent of all patients in general hospitals are admitted because of complications related to alcoholism. However, the literature has little in specific clinical pathways, treatment protocols, or guidelines for the interdisciplinary care of these patients in the acute care setting. Furthermore, the little information that is published shows a lack of consistency in recommended treatment regimes. This article reviews a coordinated, interdisciplinary effort in developing and implementing a clinical pathway for alcohol withdrawal. Copyright (c) 1998 by Aspen Publishers, Inc.  (5 ref)

251.    Schein, C., & Blair, E. (1998). Pathways to evidence-based practice. Canadian Oncology Nursing Journal, 8(1), 3-8.

252.    Nash, D. B. (1998). Physicians resist efforts to standardize care [interview]. Hospital Case Management, 6(2), 24-5.

253.    Main, B. J., & Morrison, D. L. (1998). Techniques and procedures. Development of a clinical pathway for enteral nutrition. Nutrition in Clinical Practice, 13(1), 20-4.
Abstract: Clinical pathways illustrate, sequentially, the most efficient interventions for reaching desired outcomes for various disease states or treatment modalities. With the increasing demand for high-quality, cost-effective nutrition care, the Enteral Nutrition Service developed a clinical pathway for enteral feedings. The purpose was to coordinate multidisciplinary efforts to ensure comprehensive, goal-oriented nutrition care. The pathway has two phases. Phase one focuses on initiating and optimizing inpatient enteral nutrition support. Phase two addresses the transition to oral diet and discharge planning. This pathway was designed to augment disease specific pathways already in place. In the model developed at William Beaumont Hospital, the Registered Dietitian is designated as the case manager to monitor compliance and record variances. Corresponding continuous quality improvement indicators include nutritional adequacy, complications, compliance to hospital policies, and trial of the proposed home regimen before discharge. The variances and outcomes are presented routinely to the Hospital Nutrition Committee for review and adaptation of the pathway. From both a legal and quality perspective, clinical pathways allow a proactive, multidisciplinary approach to designing the optimal treatment course.  (13 ref)

254.    Koch, L. A. (1998). Getting a grip on the future: managing the change process. Caring, 17(2), 62-4, 66, 68-70.
Abstract: How will providers streamline existing administrative and clinical care systems to meet the new regulatory requirements? How will they reorganize to cope with outcome-based quality improvement? Success in this rollercoaster climate depends on providers' ability to manage the change process.  (Abstract by: Author)

255.    Jones, A., & Norman, I. J. (1998). Managed mental health care: problems and possibilities. Journal of Psychiatric & Mental Health Nursing, 5(1), 21-31.
Abstract: Case management has become an established organizational approach to mental health care. However, a recent development of case management, known as 'managed care' has received only limited attention in the UK and this has been confined to acute medical or surgical hospital care. The potential of managed care as applied to mental health care is uncertain. This paper clarifies the nature of managed care and discusses its relevance to mental health care, in particular to the care of people suffering from schizophrenia. The high incidence and heavy resource demands of this user group makes these people an ideal focus for managed care. However, there are conceptual and practical problems hindering its development and implementation, including: the variability and unpredictability of the disease process of schizophrenia; challenges of outcome measurement; and problems relating to the current organization of mental health care.  (97 ref)

256.    Isozaki, L. F., & Fahndrick, J. (1998). Clinical pathways--a perioperative application. [Review] [35 refs]. AORN Journal, 67(2), 376, 379-386, 389-92; quiz 393-396.
Abstract: The application of clinical pathways as a means of streamlining health care and tracking outcome data for continuous quality improvement has been evolving continually since the late 1980s. In order for the clinical pathway process to be effective, it must be collaborative, multidisciplinary, and have administrative support and institutional congruency. Members of multidisciplinary work group at the University of California Los Angeles Medical Center have developed a perioperative clinical pathway for patients undergoing coronary artery bypass graft surgery. The process of developing a perioperative clinical pathway involved extensive preliminary preparation before actually designing the pathway and identifying outcome data. Ongoing reevaluation of pathway components is essential and future opportunities for expansion are apparent. [References: 35]

257.    Ibarra, V. L., Mueller, T., Rossi, N., Schillig, K., & Swearingen, J. (1998). Interdisciplinary quality improvement from the perspective of a clinical pathway team. Journal of Nursing Care Quality, 12(3), 19-29.
Abstract: Clinical pathway teams are one type of interdisciplinary team formed to improve the quality of care provided to select patient populations. As they aim to improve quality, these teams look at improving the efficiency and effectiveness of the care provided, as well as overall performance. Some clinical pathways and teams are successful, while others are not. This article describes the activities of a coronary artery bypass graft (CABG) clinical pathway team, difficulties encountered by the team, and strategies developed to overcome these difficulties

258.    Fujihara, L. F., & Fahndrick, J. (1998). Home study program: clinical pathways -- a perioperative application. AORN Journal, 67(2), 374, 376, 379-383 passim.
Abstract: The application of clinical pathways as a means of streamlining health care and tracking outcome data for continuous quality improvement has been evolving continually since the late 1980s. In order for the clinical pathway process to be effective, it must be collaborative, multidisciplinary, and have administrative support and institutional congruency. Members of multidisciplinary work group at the University of California Los Angeles Medical Center have developed a perioperative clinical pathway for patients undergoing coronary artery bypass graft surgery. The process of developing a perioperative clinical pathway involved extensive preliminary preparation before actually designing the pathway and identifying outcome data. Ongoing reevaluation of pathway components is essential and future opportunities for expansion are apparent.  (5 ref)

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

260.    Drott, M. L. (1998). Beyond the first phases of a critical path system. Hospital Case Management, 6(2), 29-32.

261.    Brooker, D., Foster, N., Banner, A., Payne, M., & Jackson, L. (1998). The efficacy of Dementia Care Mapping as an audit tool: report of a 3-year British NHS evaluation. Aging & Mental Health, 2(1), 60-70.
Abstract: Dementia Care Mapping (DCM, Kitwood & Bredin, 1994a) was incorporated into the Quality Assurance Strategy of an urban British Mental Health (NHS) Trust. Its role as an audit of the outcome of the care process in formal dementia care settings was evaluated. DCM was used in two day hospitals, an assessment ward, two respite care units and four continuing care units over three annual evaluation cycles. This equated to approximately 1,614 hours of mapping over the three cycles. The way in which DCM was used is described in detail. The results were generally very positive with improvements in the quality of care practice being demonstrated. Although anxious about She observational nature of DCM, staff viewed it as a positive means of improving quality of care. DCM is seen as being a highly appropriate audit tool to use in NHS formal dementia care settings. Information on the experience of managing a DCM project is shared.  (19 ref)

262.    Ayers, T., & Todd, T. (1998). The Maze Program. Clinical pathways in treatment for adolescents. Behavioral Healthcare Tomorrow, 7(1), 43-5.

263.   Campion, C. (1998). MI mortality outpacing new chest pain centers. Nursing Spectrum (Washington, Dc/Baltimore Metro Edition), 8(1), 6-7.

264.    Campion, C. (1998). MI mortality outpacing growth of chest pain centers. Nursing Spectrum (Greater Philadelphia/Tri-State Edition), 7(1), 4-5.

265.    Campbell, H., Hotchkiss, R., Bradshaw, N., & Porteous, M. (1998). Integrated care pathways [see comments]. [Review] [40 refs]. BMJ, 316(7125), 133-7.
Notes: Comment in: BMJ 1998 Jul 11;317(7151):147-8

266.    Broderick, J. P. (1998). Practical considerations in the early treatment of ischemic stroke. [Review] [17 refs]. American Family Physician, 57(1), 73-80.
Abstract: Successful treatment of patients with ischemic stroke depends on the ability to treat within three hours of onset, because tissue plasminogen activator has not yet been proved effective beyond this time frame. The two major causes of delay in treatment are failure, on the part of the patient or family, to recognize stroke symptoms and failure to access the medical system most efficiently--by calling 911. Hospital stroke teams can shorten the time between patient arrival at the emergency department and treatment. Guidelines for the evaluation and treatment of potential stroke patients are presented, along with goal times for arrival-to-treatment intervals. [References: 17]

267.    Phillips, K. F., & Crain, H. C. (1998). Effectiveness of a pneumonia clinical pathway: quality and financial outcomes. Outcomes Management for Nursing Practice, 2(1), 16-22; quiz 22-3.
Abstract: In today's health care environment, it is imperative to evaluate planned changes within a health care system. We report the outcomes of a study on the effectiveness of a pneumonia clinical pathway. Important elements of effectiveness studies are discussed and used in presenting study findings. These findings are a preliminary demonstration that clinical pathways can improve patient and process outcomes. Their relation to financial outcomes is less clear

268.    Fuss, M. A., & Pasquale, M. D. (1998). Clinical management protocols: the bedside answer to clinical practice guidelines. Journal of Trauma Nursing, 5(1), 4-11; quiz 27-8.
Abstract: TOPIC: Clinical Management Protocols for trauma patients. PURPOSE: The goals and process for developing and implementing Clinical Management Protocols are presented. Protocol development and the differences between clinical practice guidelines, critical pathways, and clinical management protocols are discussed. SOURCES: Published literature, experience, and clinical expertise. CONCLUSIONS: Utilizing annotated algorithms, the protocols are designed for and driven by patient care based on patient need and require the collaboration of experts and trauma team members

269.    Brown, S. W., & Nemeth, L. S. (1998). Developing a variance reporting system to facilitate quality improvement. Outcomes Management for Nursing Practice, 2(1), 10-5.
Abstract: A major challenge of clinical pathway programs is measurement of elements of patient care that affect health outcomes and applying this knowledge to institute systematic improvement. Development of a variance reporting system requires planning, teamwork, and an understanding of the underlying quality process. This article describes a sample approach for using data as part of a comprehensive strategy to reach quality and fiscal goals

270.    Tahan, H. A. (1998). The multidisciplinary mandate of clinical pathways enhancement. Nursing Case Management, 3(1), 46-51.

271.    Pestian, J. P., Derkay, C. S., & Ritter, C. (1998). Outpatient tonsillectomy and adenoidectomy clinical pathways: an evaluative study. American Journal of Otolaryngology, 19(1), 45-9.
Abstract: PURPOSE: The purpose of this study is to examine two different dimensions of an outpatient pediatric tonsillectomy and adenoidectomy (T&A) clinical pathway at a tertiary care children's hospital. First, the analysis investigates whether the T&A clinical pathway effectively aids in the decision to discharge a pediatric patient as a day surgery (DS) (less than 12 hours) rather than as an outpatient observation surgery (OPO) (12 to 23 hours). Second, the pathway's impact on quality and financial outcomes is explored. PATIENTS AND METHODS: Forty prepathway pediatric T&A patients were randomly selected and matched to 40 pathway pediatric T&A patients by age, gender, medical history, and surgeon to form a retrospective cohort. Using chi-square and analysis of variance, the two groups were compared by type of discharge (DS or OPO), length of stay, readmission rates, and costs. RESULTS: The results show that patients on a pathway were more likely to be discharged as a DS. The shift toward DS discharges effected significant reduction in average length of stay and overall direct costs. Furthermore, there was no difference in readmission rates. CONCLUSION: These results indicate that the development and implementation of a pathway is an effective method in reducing length of stay and overall direct costs while maintaining quality outcomes

272.    Higginbotham, P., & Gottlieb, A. (1998). Improving care with a pediatric appendicitis pathway. Nursing Case Management, 3(1), 26-35.

273.    Harmon, R. L., Sheehy, L. M., & Davis, D. M. (1998). The utility of external performance measurement tools in program evaluation. Rehabilitation Nursing, 23(1), 8-11.
Abstract: Many rehabilitation hospitals use formal measurement tools to evaluate program performance. A potential advantage to using the Functional Independence Measure instrument through the Uniform Data System for Medical Rehabilitation (UDSMR) is that it provides information that allows an institution to compare its level of performance to those of other facilities. To assess whether joining UDSMR, along with an institution's continuous quality improvement efforts, could be associated with improved program performance, the records of a rehabilitation hospital's internal inpatient Program Evaluation System (PES) were reviewed for 6 fiscal years (1990-1995). Quality improvement efforts during 1995 (during which a 51% improvement in length of stay efficiency was noted) included education for staff, feedback on team performance, and efforts to formulate clinical pathways. Although external measures of performance do not have a direct effect on quality improvement, they could help identify areas of potential improvement that might not be appreciated when internal assessment systems are used alone

274.    Hanson, R., & Sayers, B. (1998). Restructuring. Case management drives redesign. Recruitment, Retention & Restructuring Report, 11(1), 1-4.
Abstract: Case management is a system that should not be separate from restructuring efforts, but instead can be the driver of restructuring. Building clinical pathways, key components of case management, can help increase multidisciplinary spirit, focus on patient-centered outcomes, decrease wide variations in practice patterns, and accent the role of the RN as coordinator of the team.

275.    Behrendt, D. (1998). Home care and clinical paths--steps toward more effective care. [Review] [6 refs]. Health Care Innovations, 8(1), 23-6.

276.    Wagner, L. (1998). Implementing critical pathways. Provider, 24(1), 61-2.

277.    Spath, P. L. (1998). Do homework before starting on pathways. Or-Manager, 14(1), 19-20.

278.    Schooler, M. P. (1998). A clinical pathway for patients undergoing minimally invasive direct coronary artery bypass surgery. AORN Journal, 67(1), 237-41.

279.    Rook, D. (1998). Cardiac surgery pathway cuts postoperative intubation time in half. Hospital Case Management, 6(1), 9-12.

280.    Rainwater, J. A., Romano, P. S., & Antonius, D. M. (1998). The California Hospital Outcomes Project: how useful is California's report card for quality improvement? [see comments]. Joint Commission Journal on Quality Improvement, 24(1), 31-9.
Notes: Comment in: Jt Comm J Qual Improv 1998 Jan;24(1):50-1
Abstract: BACKGROUND: Hospital report cards have proliferated in the 1990s but remain controversial because risk-adjusted outcomes measures are complex and have uncertain validity. Despite this controversy, little is known about their value and impact. METHODS: A two-stage survey of hospital leaders in California was undertaken in September 1996 and July 1997 to explore how the 1996 reports and data from the California Hospital Outcomes Project (CHOP) were used to improve organizations' performance. In the first stage, a questionnaire was mailed to the chief executive officer of each hospital in the report. In the second stage, a stratified random sample of the respondents who indicated a willingness to provide further information was interviewed. RESULTS: Thirty-nine interviews were completed, representing 87% yield after replacing informants who failed to return six messages. About three-quarters of the interviewees found some aspect of the CHOP report to be useful, especially for benchmarking performance, improving ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) coding, and educating physicians about documentation and clinical pathways. The most common criticisms were that the reports were not timely and described death rates without providing practical information about the process of care. DISCUSSION: Although the 1996 CHOP reports and data were widely disseminated within hospitals, most reported uses did not directly affect the process of care for patients with acute myocardial infarction. This finding reflects two critical weaknesses of the project--nontimely data and lack of information about the process of care. Nevertheless, hospital quality managers recognize that public report cards are here to stay, and some carefully studied their outcomes data to identify areas for improvement

281.    Radtke, W. A. (1998). Current therapy of the patent ductus arteriosus. [Review] [48 refs]. Current Opinion in Cardiology, 13(1), 59-65.
Abstract: The patent ductus arteriosus (PDA) was the first congenital heart lesion to be treated surgically and also the first to be treated with nonsurgical catheter intervention. Surgical ligation and division of the ductus remains the gold standard for consistently achieving complete occlusion. Transaxillary muscle-sparing thoracotomy and video-assisted thoracoscopic ligation, however, have evolved as surgical alternatives with reduced trauma, shorter hospitalization, and excellent cosmetic result but are associated with a significant rate of residual or recurrent duct patency. With aggressive application of critical pathway methods, significant reduction in cost has been achieved for surgical PDA closure. Nonsurgical transcatheter closure nevertheless has gained widespread acceptance, mostly employing detachable or nondetachable stainless steel coils. Coils have superseded the previously popular Rashkind PDA occluder (USCI/Bard, Tewksbury, MA) because of significantly lower cost, less cumbersome handling, smaller delivery catheters, and superior occlusion rates. Various coil implantation techniques and detachment mechanisms have been devised. Large PDAs with smallest diameter greater than 5 mm, however, still are better treated surgically until appropriate devices become available. [References: 48]

282.    Meurier, C. E. (1998). The quality of assessment of patients with chest pain: the development of a questionnaire to audit the nursing assessment record of patients with chest pain. Journal of Advanced Nursing, 27(1), 140-6.
Abstract: The quality of nursing and medical records has been a source of concern for many years (Audit Commission 1995). This study has two main purposes: firstly, to design an audit questionnaire to evaluate the quality of nursing assessment records of patients with chest pain; and secondly, to make some tentative conclusions about the quality of nursing assessment of patients with a chest pain in order to pinpoint areas that need further study. A sample of 30 patients was selected for this study on the basis of some well-defined inclusion criteria. The nursing assessment notes of these patients were evaluated using the audit questionnaire. It was found that the questionnaire was effective in gleaning appropriate information from the nursing notes to be able to derive some tentative conclusions about the quality of nursing assessment of patients with chest pain, i.e., on the whole nursing assessment was found to be superficially carried out, potentially making errors of omission and commission likely to occur. The inter-rater reliability of the questionnaire was found to be good. The questionnaire also seems to measure what it purports to measure (i.e. has content validity). However, this needs to be further checked by using a larger sample

283.    Mathias, J. M. (1998). Build variance tracking into pathway program. Or-Manager, 14(1), 21-2.

284.    Inamura, K., & Inoue, T. (1998). [Selection of clinical evaluation criterion and method of measurement]. [Review] [4 refs] [Japanese]. Gan to Kagaku Ryoho [Japanese Journal of Cancer & Chemotherapy], 25(1), 7-12.
Abstract: The criterion for clinical evaluation of radiotherapy is defined by the authors as follows: Cost-effectiveness = Quality adjusted life year of a patient divided by the expenditure for the patient. Here, quality adjusted life year is calculated by estimating transition probabilities employing the Malkov process model. An expression model for estimation of radiotherapy effectiveness of the patient was proposed and applied. The actual cost of radiotherapy for the patient was calculated by carrying out a Care Map Study in a radiotherapy facility. The time study measures, the hours spent treating the patient by the kind of medical staff. Then, cost-effectiveness was calculated using these two variables in 2,926 patients from 147 radiotherapy facilities collected from a multi-institutional radiation oncology database developed and operated for the five years. A worksheet composed of 55 items of radiotherapy record for one site of a patient. Another worksheet for patient follow-up was composed of 14 items. Six retrospective and prospective data collections and three follow-up investigations were carried out. This study intended to determine the cost-effectiveness of radiotherapy in terms of cancer sites, diseases and treatment modalities. A further target is to expand this method to evaluate new technologies of health care at large as well as radiation oncology. [References: 4]

285.    Huggins, C. M., & Phillips, C. Y. (1998). Using case management with clinical plans to improve patient outcomes. Home Healthcare Nurse, 16(1), 14-20.
Abstract: A case-management approach using clinical plans was developed to enhance outcomes. Patients with congestive heart failure (CHF) who were admitted to home care and case managed by nurses specially trained in cardiovascular nursing, case management, and the use of a clinical plan, had improved outcomes with fewer visits than patients with CHF managed with traditional care practices. Quality management and cost-effectiveness of patient care may be positively affected when using this approach.  (7 ref)

286.    Gillinov, A. M., & Heitmiller, R. F. (1998). Strategies to reduce pulmonary complications after transhiatal esophagectomy. Diseases of the Esophagus, 11(1), 43-7.
Abstract: BACKGROUND: By eliminating a thoracotomy, transhiatal esophagectomy (THE) is purported to reduce postoperative pulmonary complications. However, data from many early series do not support this contention, documenting pulmonary complications in up to 50% of patients and pneumonia in 5%-20%. Since 1990, we have implemented a management strategy designed to maximize airway protection in the postoperative period. The purpose of this study was to determine the current incidence of pulmonary complications after transhiatal esophagectomy without thoracotomy. PATIENTS AND METHODS: From 1990 to 1995, 101 consecutive patients underwent THE. Surgical indications were esophageal carcinoma (90 patients) and Barrett mucosa with high-grade epithelial dysplasia (11 patients). Mean age was 60.2 +/- 1.2 years; 89 patients were male. Eighty-two patients were smokers and 26 had chronic obstructive pulmonary disease (COPD). Sixty-five patients were American Society of Anesthesiologists risk score 3 or 4. Postoperatively, all patients were managed according to a standardized clinical pathway that included overnight mechanical ventilation, chest physiotherapy, video pharyngo-esophagram postoperative day 6 or 7, and graduated post-esophagectomy therapeutic diet after acceptable esophagram. RESULTS: Pulmonary complications were classified as major or minor depending upon whether or not a change in therapy was required. Ten patients (10%) had 11 major pulmonary complications. These included pneumonia (3), pleural effusion requiring drainage (4), exacerbation of COPD (2), and mucus plug requiring bronchoscopy or intubation (2). Minor pulmonary complications identified by chest film were atelectasis (97), pleural effusion (85), and pneumothorax (3). Patients with major pulmonary complications were older (69.3 +/- 9.8 vs. 59.2 +/- 12.1 years, p < .02) and more likely to have COPD (70% vs. 21%, p < .005) than those with only minor complications. There were 3 operative deaths; 2 caused by pneumonia and 1 by fungal sepsis in a patient who had exacerbation of COPD. Mean hospital length of stay was 13.1 +/- 1.4 days. CONCLUSIONS: Minor pulmonary complications identified by chest film occur in nearly all patients undergoing THE. Strict adherence to a management protocol designed to maximize airway protection in the postoperative period results in a 10% incidence of major pulmonary complications. Older patient age and COPD are risk factors for major pulmonary complications after THE. Although pneumonia is uncommon, it remains the most frequent cause of death after THE

287.    Garza, M. A. (1998). EMS 2000. Part I. High-tech triage. Journal of Emergency Medical Services : Jems, 23(1), 32-41.

288.    Danne, P., Brazenor, G., Cade, R., Crossley, P., Fitzgerald, M., Gregory, P., Kowal, D., Lovell, L., Morley, P., Smith, M., Taylor, R., & Walker, S. (1998). The major trauma management study: an analysis of the efficacy of current trauma care. Australian & New Zealand Journal of Surgery, 68(1), 50-7.
Abstract: BACKGROUND: An audit of the management and outcome of major trauma patients was carried out to determine ways in which the system of care may be improved. METHODS: The Major Trauma Management Study (MTMS) collected data prospectively on all consecutively admitted major trauma patients at eight major hospitals during a 12-month period. Outcome was studied using trauma and injury severity score (TRISS) and a severity characterization of trauma (ASCOT) analyses, as well as a preventable outcome analysis, which looked at survivors with complications or with a Glasgow Coma Score < 15 on discharge from hospital, as well as studying deaths. RESULTS: The group of 859 patients was more severely injured than most described previously, with a mortality of 14.8% and a mean injury severity score of 19.8. Formal ASCOT analysis indicated 2.25% fewer survivors than would be predicted by Major Trauma Outcome Study norms. Extrapolating the TRISS and ASCOT process to include those patients with missing data, and then comparing groups of matched severity with the norms, gave no statistically different outcome in the MTMS group of patients. Preventable outcome analysis revealed rates of preventable and potentially preventable (P/PP) outcomes of 32% among deaths and 8% among survivors. The types of management deficiencies responsible for P/PP outcomes are identified. CONCLUSIONS: The points of deficiency in a system of care have been identified, and the development of an integrated trauma system in Victoria, based upon these facts, is recommended. Children, the elderly, patients with head injuries and patients being transferred between hospitals would benefit from improvements to the system of care. The calculation of efficacy rate (0.95 for the MTMS patients) is recommended to accurately assess the system of care. Preventable Outcome Analysis is more relevant to auditing a system of trauma care in detail, than is ASCOT or TRISS. The MTMS has refined and defined the process so that it is reproducible in further comparative studies

289.    Dahl, S. (1998). Viewpoint. Navigating clinical pathways. Surgical Services Management., 4(1), 10-11.

290.    Citrome, L. (1998). Practice protocols, parameters, pathways, and guidelines: a review. [Review] [49 refs]. Administration & Policy in Mental Health, 25(3), 257-69.
Abstract: The evolution of clinical practice protocols is described within the context of its origins in utilization review and utilization management. Physician concerns and barriers to implementation, as well as the role of the Agency for Health Care Policy and Research (AHCPR) are discussed. An example of competing guidelines from the AHCPR and the American Psychiatric Association is described in detail. The available literature on cost savings related to utilization management and clinical guidelines is reviewed and summarized. With over 1,800 medical practice guidelines catalogued, practice protocols have become ubiquitous and continued research into their cost and impact on quality are needed. [References: 49]

291.    Calligaro, K. D. (1998). Regarding "Impact of a critical pathway on the results of carotid endarterectomy in a tertiary care university hospital: effect of methods on outcome" [letter; comment]. Journal of Vascular Surgery, 27(1), 190-1.
Notes: Comments: Comment on: J Vasc Surg 1997 Aug;26(2):186-92

292.    Burns, S. M., Marshall, M., Burns, J. E., Ryan, B., Wilmoth, D., Carpenter, R., Aloi, A., Wood, M., & Truwit, J. D. (1998). Design, testing, and results of an outcomes-managed approach to patients requiring prolonged mechanical ventilation. American Journal of Critical Care, 7(1), 45-57; quiz 58-9.
Abstract: BACKGROUND: Outcomes management that uses critical pathways may decrease costs while improving outcomes for patients who require prolonged mechanical ventilation. OBJECTIVE: To study the efficacy of an outcomes-managed approach to weaning patients from prolonged (more than 3 days) mechanical ventilation. METHODS: A method of multidisciplinary care delivery was designed that included an outcomes manager, a care pathway for patients receiving mechanical ventilation, and weaning protocols. Data collection consisted of three parts: a retrospective review of 124 patients who required prolonged ventilation during a 1-year period before implementation of the care model, a 6-month prospective study in which 91 patients were alternately assigned by month to an outcomes-managed approach or a non-outcomes-managed approach, and a 6-month prospective study of 90 patients in which an outcomes-managed approach without alternate-month assignment was used. RESULTS: Outcomes management had no significant effect on total duration of mechanical ventilation or length of stay in the hospital, days of mechanical ventilation without tracheostomy, days of mechanical ventilation with tracheostomy, or outcome (weaned, withdrawal from mechanical ventilation, death, or transfer without weaning). However, duration of mechanical ventilation was 1.3 days shorter, length of stay in the hospital was 2.1 days shorter, and the cost per case was $ 3341 less for patients in the outcomes-managed group than for patients in the non-outcomes-managed group. CONCLUSION: Outcomes-managed care did not have a significant effect on duration of ventilation, length of stay in the hospital, or outcome in patients receiving long-term mechanical ventilation

293.    Bailey, R., Weingarten, S., Lewis, M., & Mohsenifar, Z. (1998). Impact of clinical pathways and practice guidelines on the management of acute exacerbations of bronchial asthma. Chest, 113 (1), 28-33.
Abstract: OBJECTIVES: In 1990, it was estimated that approximately 1% of all US health-care costs (approximately $6.2 billion) were spent on asthma-related health expenses. Of this, hospitalization charges alone exceeded $2.6 billion. Practice guidelines and clinical pathways are being developed to standardize the management of acute asthma with the aim of improving care and safely reducing health-care costs. In this report, we evaluate the impact of an asthma pathway developed and instituted at a large community-based teaching hospital. This pathway was evidence based and was developed by a multidisciplinary group. METHODS: The study was conducted during a 6-month period in 1995, while a similar period in 1994 was used as a historical control period. Data collected included patient demographics, hospital admission and discharge peak expiratory flow rates, pulse oximetry measurements, length of stay, conversion from hand-held nebulizer to metered-dose inhaler, use of corticosteroids within 24 h of hospitalization, and conversion of i.v. steroids to oral steroids. RESULTS: A total of 42 patients were enrolled during the study period. Of these, 19 were placed on the pathway, while 23 were not treated according to the pathway. There were 38 patients in the 1994 historical control period. For 1995, there was no significant difference between the pathway and nonpathway groups with regard to the length of stay (4.4+/-3.3 vs 3.2+/-2.3 days; p > 0.05), hospital discharge peak expiratory flow rates (324 vs 286 L/min; p > 0.05), or use of steroids (100% vs 91%; p > 0.05). However, a significant increase in conversion from hand-held nebulizer to metered-dose inhaler was noted in the pathway group (68% vs 34%; p < 0.05). The data from 1994 compared to 1995 pathway were similar in that there was no difference in the length of stay (3.4+/-2.1 vs 4.4+/-3.3 days; p > 0.05) and/or use of steroids (92% vs 100%; p > 0.05), while a significant increase in hand-held nebulizer to metered-dose inhaler conversion was observed for the 1995 pathway group (68% vs 26%; p=0.002). CONCLUSIONS: We conclude that although the asthma pathway did not significantly reduce length of stay, it was associated with a significant increase in hand-held nebulizer to metered-dose inhaler conversion, resulting in a substantial cost savings of $288,000/year

294.    Yorioka, N., Taniguchi, Y., Yamashita, K., Ueda, C., Nakamura, C., Harada, S., & Yamakido, M. (1998). Tissue factor and tissue factor pathway inhibitor in hemodialysis patients. International Journal of Artificial Organs, 21(11), 699-701.
Abstract: Tissue factor and tissue factor pathway inhibitor are important in extrinsic coagulation. We investigated their clinical significance in hemodialysis patients. We took blood samples, prior to initiation of routine hemodialysis, from 73 patients on hemodialysis (35 men and 38 women aged 56.1 +/- 11.7 years on dialysis for 82.1 +/- 61.0 months), and determined tissue factor and tissue factor pathway inhibitor levels by ELISA. In the patients the tissue factor level was 704.5 +/- 141.6 pg/ml and the tissue factor pathway inhibitor level was 44.5 +/- 23.3 ng/ml; both values were significantly higher than in normal controls (192.7 +/- 36.6 pg/ml and 18.6 +/- 5.7 ng/ml, respectively). In patients with shunt obstruction, tissue factor pathway inhibitor levels were significantly higher than in those without it. Therefore, the tissue factor pathway inhibitor level may be a marker of shunt obstruction.  [References: 12]

295.    Wang, A., Ackland, T., Hall, S., Gilbey, H., & Parsons, R. (1998). Functional recovery and timing of hospital discharge after primary total hip arthroplasty. Australian & New Zealand Journal of Surgery, 68(8), 580-583.
Abstract: Background: Early discharge programmes in hospitals are encouraged to increase financial efficiency and bed availability, but standards of clinical care must not be compromised. Criteria for safe hospital discharge must be established and objective data are needed to assess how rapidly patients can achieve these discharge criteria. Methods: A prospective study was performed on 65 patients (mean age = 71 years) scheduled for primary total hip arthroplasty (THA). The Modified Barthel Index (MBI) was measured pre- operatively and postoperatively at set intervals to assess recovery of function after THA. A score of 90 out of a possible 100 was used as a discharge criterion and indicated that the patient was functionally independent for safe hospital discharge. In addition, a combined score for thigh flexion and extension isokinetic peak strength was recorded for each patient before and after surgery. The number and nature of comorbidities and complications were also recorded. Results: The length of hospital stay in this sample varied from 5 to 39 days. The MBI scores increased rapidly between days 3 and 5, then began to plateau from day 8 onwards. Based on the MBI, 58% of patients were fit for discharge at or before day 8. The remainder were fit for discharge from day 10 onwards (mean = 14.2 days). The latter group who required an extended hospital stay were older (P= 0.003), had more identified comorbidities (P = 0.01) and were weaker in their hip musculature prior to surgery (P = 0.01), compared to those who were discharged by day 8. A logistic regression analysis indicated that the pre-operative MBI score and hip strength score were strong predictors of timing for hospital discharge. Conclusions: A clinical pathway with functional milestones laid out over 8 days would be an appropriate criterion for the discharge of the majority of patients. However, approximately 40% of the patients presented in this study required a longer hospital stay before the criteria for safe discharge could be achieved. These patients can be identified pre-operatively by screening their MBI and composite hip strength scores.  [References: 8]

296.    Waintraub, L. (1998). Recognizing and treating depression in the elderly. Presse Medicale, 27(40), 2129-2144.

297.    Tobin, M. J., Hickie, I. B., & Hudson-Jessop, P. (1998). Clinical practice guidelines and clinical pathways: Defining the tasks and the implications for public sector mental health systems. AUSTRALAS PSYCHIATRY, 6(6), 303-305.
Abstract: Current health policy emphasises the need for greater accountability. One response has been a move to develop clinical practice guidelines. These are defined as 'systematically developed statements to assist practitioner decisions about appropriate health care for specific clinical circumstances' [1]. Based upon components of evidence based medicine, such guidelines aim to ensure best practice. The engagement of participants in the process should lead to the identification of gaps in knowledge and provide further degrees of evidence. The National Health and Medical Research Council (NHMRC) has indicated that 'the main purpose of guidelines is to achieve better health outcomes by improving the practice of health professionals and by better informing consumers about treatment options. Guidelines can also be used in the broader education of practitioners and the community and can contribute to quality assurance processes. Finally, they may assist in the resolution of legal disputes and ethical dilemmas' [2].  [References: 19]

298.    Teo, K., Martin, S., Montague, T., Montague, P., Tymchak, W., Burton, J., Humen, D., Barnes, M., Taylor, L., Wowk, L., Fassbender, K., Warnica, W., Smith, B., Greenwood, P., Prosser, A., Tsuyuki, R., Nilsson, C., Lo, A., Stevens, K., Kuritzky, R., Imrie, J., Marquis, J., Ashton, T., Bart, D., McLeod, D., Cates, L., Kornder, J., Breakwell, L., Morris, A., Schillberg, M., Robinson, K., Ackman, M., Fassbender, K., Ikuta, R., McAlister, F., Bay, K., Yim, R., & Dowding, G. (1998). Influence of a critical path management tool in the treatment of acute myocardial infarction. American Journal of Managed Care, 4(9 SUPPL.), 1243-1451.
Abstract: Objective: The primary objective of this study was to determine the effect of implementing a critical path on use of proven efficacious therapies and outcomes in patients admitted to a hospital with acute myocardial infarction (AMI). The secondary objectives were to evaluate the use of unproven medications and to develop an understanding of the factors associated with adverse in-hospital outcomes in these patients. Study Design: A nonrandomized before-after study design was used to evaluate the efficacy of a critical path instrument in patients admitted to hospital with AMI. Patients and Methods: Consecutive patients admitted with AMI in nine participating hospitals were enrolled in the study. The critical path instrument consisted of a locally developed, preprinted physician order form. Practice patterns were determined before (n=2305) and after (n=2349) implementation of the critical path by primary chart review. Multivariate analysis of risk factors for mortality was performed on a combined database of 6088 AMI patients. Results: The use of acetylsalicylic acid (ASA), nitrates, and beta blockers increased significantly by 3%, 2%, and 9%, respectively, after implementation of the critical path. Use of thrombolytics remained stable at 41%, and calcium channel blocker use decreased significantly by 8%. In-hospital mortality decreased by 1%. There was less use of ASA, nitrates, beta blockers, and thrombolytic therapy in women and the elderly. Multivariate analysis showed that advanced age was associated with increased mortality risk, whereas ASA, beta blockers, nitrates, and calcium channel blockers were associated with reduced mortality risk. Conclusion: Implementation of a critical path resulted in increased use of proven efficacious therapies, reduced use of noneffective therapy, and a trend toward reduced mortality.  [References: 22]

299.    Samama, M. M., & Kher, A. (1998). Anticoagulation: The old and the new. Hamostaseologie, 18(4 SUPPL. A), S27-S32.

300.    Pousma, D. J., & McNamara, T. J. (1998). Clinical decision support for drug therapy selection in the elderly. In Toward an electronic patient record '98: proceedings, volume two  (pp. 126-129). Newton, MA: MRI.
Abstract: BACKGROUND. The purpose of this study was to evaluate the differences between 176 clinical practice guidelines for geriatric patients and a similar number of clinical practice guideline for non-geriatric adult patients.  This study was sponsored by the National Institutes of Health as part of a small business innovation research grant.  METHODS AND RESULTS. After careful review of recent data and medical literature 352 clinical practice guidelines were written by physicians and reviewed by experts (defined as board certified physicians within a given specialty.  The practice guidelines were entered into software using a novel data entry tool.  The data entry tool was designed to enable users to "drill down" into specific treatment recommendations (drug or non-drug therapy).  Comparison of the clinical practice guidelines revealed 86 conditions (49%) for which there were significant differences in recommended therapy between geriatric and non-geriatric adult populations.  Among the 86 conditions, there were 44 conditions (51%) for which expert physicians would recommend more aggressive therapy for geriatric patients, 33 conditions (38%) for which they would recommend significantly different drug choices, 32 instances (37%) for which they warn of significantly higher risks of drug toxicity, and 19 conditions (22%) for which expert physicians would recommend significantly lower initial drug dosages.  CONCLUSIONS. The use of clinical practice guidelines can increase awareness of special recommendations in the practice of geriatric medicine.  Additional data are needed to examine the clinical benefit and cost-effectiveness of such guidelines in geriatric patient populations and others.  The use of clinical practice guidelines has been shown to increase the consistency, safety, and cost-effectiveness of health care in many cases.  However, clinical pathways have not been well accepted by physicians in the U.S.  Data have shown that factors that affect the adoption of clinical practice guidelines include quality of the guidelines, characteristics of the health care professional, characteristics of the practice setting (habits, customs, peer influence, social norms, and so forth), incentives (legal or financial), the necessity of adherence to regulatory or accreditation standards (JCAHO), and the complexity of a given patient's case.  In some cases, acceptance of clinical practice guidelines has improved when users are granted continuing medical education credits when studying and using them.  Physicians have been more receptive of clinical practice guidelines that were uncomplicated and observable compared with guidelines that were complex and inconsistent with their existing beliefs and values.  Younger doctors may be more inclined toward the concept of clinical practice guidelines compared with older doctors.  It is possible that allowing physicians to customize or at least edit guidelines make them more acceptable.  The use of clinical practice guidelines may be very helpful when treating certain groups of patients, such as geriatric patients.  Older patients make up a growing proportion of the population, require a significant amount of healthcare, are sicker, and are more likely to develop an adverse event after an encounter with the medical profession.  This study was designed to quantify the differences between clinical treatment guidelines for geriatric and adult non-geriatric patients.  Application of such expert recommendations for "at risk" populations may be beneficial.  (Abstract by: Author)

301.    Porter, H. B. (1998). Health resource utilization and quality of life outcomes of low-risk coronary artery bypass graft patients: a comparison study. Canadian Journal of Cardiovascular Nursing, 9(1), 10-5.
Abstract: Coronary artery bypass graft surgery (CABG), undertaken because of a decline in quality of life (QOL), is known to decrease morbidity and mortality, but it is expensive. At University Campus, London Health Science Centre, (UC-LHSC), a clinical path for CABG patients categorized as low-risk by UC-LHSC was developed to decrease the costs of CABG surgery through a shortened hospital stay while maintaining quality of patient care. The purpose of this research was to compare traditional care of the CABG patient with the care of those on the Clinical Path for Coronary Artery Bypass Graft Patients on health resource utilization (HRU) and QOL outcomes 6 to 12 months post surgical discharge. The results of this study showed that while the experimental group made significantly more emergency department visits than did the control group, the groups did not differ on the health resource utilization categories of extra office visits, home care, or hospital admission. It was also found that within the experimental (Clinical Path) group there were significantly fewer extra office or clinic visits required by the subjects who received the Preadmission Program than by the participants who did not receive this program. No differences were found in quality of life 6 months after CABG surgery between low-risk patients receiving traditional care and those patients on the CABG Clinical Path. Results of this study have increased understanding of the impact of a shorter hospital stay upon CABG patients and on the health care system

302.    Parsons, M. L., Murdaugh, C. L., & O'Rourke, R. A. (1998). Interdisciplinary case studies in health care redesign. Gaithersburg, MD: Aspen Publishers.

303.    Ober, N. S. (1998). Pharmacoeconomic impact of appropriate clinical pathways. American Journal of Managed Care, 4(10 SUPPL.), S555-S561.
Abstract: Dr. Ober is president and chief executive officer of Synergy Health Care, Inc, based in Waltham, Massachusetts. In response to the concerns of managed care organizations, provider groups, and hospital systems, Synergy Health Care has worked with these entities to evaluate their antibiotic use data and help them determine effective clinical pathways for antimicrobial use. The program, called the Respiratory Infection Management System (RIMS), aims to develop a comprehensive profile on the total cost of the care in the treatment of adult respiratory infections. The company has completed a similar program involving peptic ulcer disease treatment for 35 different organizations. These programs aim to help the practicing physician at the point of care.

304.    O'Dowd, L. C., & Panettieri, R. A. Jr. (1998). Major components of an asthma disease management programme. Disease Management & Health Outcomes, 4(5), 243-253.
Abstract: In an effort to improve patient outcomes and reduce resource use and costs associated with asthma care, asthma disease management programmes have now gained momentum. If a programme is to be effective, the identification of goals and outcomes relevant to the target populations is essential. These may include strategies aimed at reducing the use of resources, improving patient symptom scores and quality-of-life measures, or normalising pulmonary function. Methods to measure such outcomes should be developed in the design phase of the programme. The best practice model for asthma care incorporates a multidisciplinary approach, using asthma care specialists, case managers, primary care physicians and nurse educators to target 'high-risk' asthmatics. The key interventions include incorporating clinical pathways developed from evidence-based guidelines, patient education and removal of obstacles to care and adherence. Assessment of outcomes and continuous efforts to improve quality are needed to make the programme cost effective.  [References: 71]

305.    Molyneux, E., & Malenga, G. (1998). Forms of better care. World Health Forum, 19(2), 201-4.
Abstract: The introduction of forms called critical care pathways into the paediatric unit of a hospital in Malawi has strengthened teamwork and helped to increase the efficiency with which resources are employed. They serve the dual function of indicating good management and providing an opportunity to note actions and potential progress

306.    Middleton, S., & Roberts, A. (1998). Clinical pathways: Development and implementation. J INTEGR CARE, 2(1), 5-7.

307.    Mechanic, D. (1998). Public trust and initiatives for new health care partnerships. Milbank Quarterly, 76(2), 281-302.
Abstract: Effective communication between doctor and patient is a critical component of high-quality care. The physician's credibility has a significant effect on treatment outcomes. Because changes in medicine and larger cultural trends challenge the ability of clinicians to engage their patients' trust, new kinds of partnerships must be created. To do this effectively, physicians have to sharpen their communication skills and devise strategies for assuring that their patients become informed allies in their own treatment. A number of innovations are helping to build these alliances: training in communication skills; creative uses of the Internet and videotape technologies; improved "customer service" programs; critical pathways for patients; and special educational aids. All these tools promise to be useful, but they require careful development and evaluation

308.    McKinley, W. O. (1998). Innovations in the care of individuals with spinal cord injury. Journal of Vocational Rehabilitation, 10(2), 153-157.
Abstract: Spinal cord injury (SCI) results in catastrophic and lifelong neurologic and functional changes. This article discusses recent innovations in the management of individuals with SCI, such as: (1) cost-effective health services via 'clinical pathways' and 'case management' approaches over the continuum of care; (2) recent clinical research into key prognostic indicators for neurological recovery after SCI; (3) innovations in the care and treatment of medical complications resulting from SCI; (4) recent and future advances in electrical stimulation to muscles and nerves to assist movement and functional control; and (5) ongoing basic science and clinical research dealing with the repair and cure of SCI. Exciting innovations are expected to continue in the research and in the management of individuals with SCI which will enhance the delivery of coordinated, comprehensive and cost-efficient care for this population.  [References: 10]

309.    McDowell, S. E. (1998). Managing change: between chaos and control. In HIMSS '98. Imagine the future: proceedings of the 1998 Annual HIMSS Conference, February 22-26, 1998, Orlando, Florida, Volume 4  (pp. 169-184). Chicago, IL: HIMSS.

310.    McCarty, J., & Dyk, L. (1998). Therapeutic pathways for antimicrobial use: Pediatric issues. American Journal of Managed Care, 4(10 SUPPL.), S550-S554.
Abstract: This presentation details Dr. McCarty's experience with the development and implementation of antimicrobial clinical pathways at Valley Children's Hospital in Fresno, California, where he is the Medical Director of Infectious Diseases. The hospital has several hundred beds, serves 700,000 children in central California, and has recently developed a physician's association including 250 physicians. The first capitated contract was received in 1997 covering 12,000 patients, and it is expected that capitated contracts covering up to 200,000 patients will be secured by the end of 1999. The first therapeutic pathway was developed as part of the new managed care organization's utilization management strategic plan, and substantial cost savings were realized while outcomes were maintained. Physician cooperation with the therapeutic pathway concept has increased, and plans are underway to develop therapeutic pathways that will be equally as effective for other disease states commonly encountered in this specialized patient population.  [References: 3]

311.    Lozano, G., & Liu, G. (1998). Mouse models dissect the role of p53 in cancer and development. [Review] [56 refs]. Seminars in Cancer Biology, 8(5), 337-44.
Abstract: Mice lacking one or two copies of the p53 gene have provided invaluable insight into the process of tumorigenesis. The importance of apoptosis in suppression of tumorigenesis in vivo became evident from analysis of these mice. Moreover, the timing and kinds of tumors that develop in these mice are altered by the presence of additional inherited mutations, by strain differences, and by food intake. Developmental abnormalities are also visible in mice with loss of p53 and with overexpression of p53 suggesting that p53 levels are critical for normal cellular processes. While mice do not necessarily recapitulate all the tumor types found in inherited cancers, they offer the unique opportunity to decipher the critical pathways in tumorigenesis. These findings can then be applied to humans. [References: 56]

312.    Lohman, H. (1998). Occupational therapists as case managers. Occupational Therapy in Health Care, 11(3), 65-77.
Abstract: Occupational therapists in today's health care environment are challenged to take on new roles such as case management. In assuming these roles occupational therapists need an understanding of the basic competencies to perform the job. To determine these competencies, the author, an occupational therapist, compares the basic competencies necessary to practice as a certified case manager and as a certified occupational therapist. As a participant/observer of case management she considers these competencies in clinical practice. From that experience she identifies strengths and suggestions for further occupational therapy educational development.  (32 ref)

313.    Lineberger, C. K., & Lubarsky, D. A. (1998). Anesthesia for carotid endarterectomy. Current Opinion in Anaesthesiology, 11(5), 479-484.
Abstract: Patients presenting for carotid endarterectomy provide anesthesiologists with many challenges. These include optimization of cerebrovascular hemodynamics and oxygen balance, as well as minimizing myocardial risk. Fiscal pressures have encouraged the development of clinical pathways in many centers, with a remarkable trend towards decreased intensive care unit utilization and length of hospital stay. Anesthetic and surgical practices vary widely, but outcomes in these high-risk patients are usually excellent despite these differences. The potential for expanded indications for carotid endarterectomy and development of percutaneous treatment for carotid stenosis will provide neurovascular anesthesiologists with additional incentives to refine the anesthetic management of these patients.  [References: 25]

314.    Leibman, B. D., Dillioglugil, O., Abbas, F., Tanli, S., Kattan, M. W., & Scardino, P. T. (1998). Impact of a clinical pathway for radical retropubic prostatectomy. Urology, 52(1), 94-99.
Abstract: Objectives. Cost containment has become an important issue in medical practice. With the implementation of collaborative care programs and critical pathways, substantial reduction in overall costs can be achieved while maintaining the quality of care and patient satisfaction. Methods. Our series consists of 856 consecutive patients treated with radical retropubic prostatectomy by 24 surgeons in a single hospital between January 1, 1994, and January 31, 1997. A clinical pathway for radical retropubic prostatectomy was implemented July 1, 1994. The patients were subdivided into three groups: (1) baseline: patients who underwent surgery in the 6 months immediately before the pathway onset (n = 113); (2) nonpathway: 75 patients treated off the clinical pathway; and (3) pathway: 668 men placed on the clinical pathway. We compare average length of stay and average hospital charges among the three groups. We also compare average length of stay among physician volume groups: high volume physicians performed at least 12 operations per year; low volume physicians performed less than 12 operations per year. Charges were further broken down by department. Patient satisfaction was recorded by an outside source after discharge. Postoperative complications were assessed in the clinical pathway and nonpathway groups. Results. Average hospital charges and average length of stay were $12,926 and 5.8 days for baseline patients, $11,795 and 5.0 days for nonpathway patients, and $10,042 and 4.0 days for pathway patients, respectively. Implementation of the clinical pathway was associated with lower charges and length of stay in the pathway group as well as the nonpathway group, with larger reductions in pathway patients. With continuous reassessment and modification of the clinical pathway, both average hospital charges and average length of stay have progressively decreased from $10,540 and 4.9 days in 1994 to $8766 and 2.7 days in January 1997. Charges were uniformly reduced in radiology, laboratory, pharmacy, operating room, anesthesia, and nursing or routine care. Patient satisfaction was similar in the pathway group and the nonpathway group. Incidence of postoperative complications did not differ significantly between the pathway and nonpathway groups. Length of stay and hospital charges were significantly lower for high than low volume surgeons, irrespective of the declines observed over time (P = 0.0001 and 0.0001, respectively). Conclusions. Average hospital charges and average length of stay for all surgeons were lowered significantly with the implementation of a clinical pathway and continue to decrease with continuous reassessment. The pathway was not associated with any increase in postoperative complications or patient dissatisfaction. Surgeons who operate frequently have lower average lengths of stay and hospital charges than those who operate infrequently.  [References: 18]

315.    Lafferty, C. L. (1998). Transformational leadership and the hospice R.N. case manager: a new critical pathway. [Review] [62 refs]. Hospice Journal, 13(3), 35-48.
Abstract: This article asserts that in light of changing conditions in the healthcare environment, transformational leadership is the most appropriate leadership style for the hospice registered nurse case manager. The author defines transformational leadership and, tracing from early leadership theories, demonstrates how the transformational-transactional leadership paradigm emerged from preceding leadership theories. The components of transformational leadership--transformational behavior and transformational characteristics--are linked to hospice theory and hospice-specific nursing practices. The expanding role of the hospice R.N. case manager is addressed in light of transformational leadership and culture building. Specific actions are proposed in the arenas of research, education, and community, corporate, and legislative involvement. [References: 62]

316.    Iyer, R. K., Quast, M., & Worsham, C. (1998). Patient satisfaction: a guide to reengineering the day surgery unit. In HIMSS '98. Imagine the future: proceedings of the 1998 Annual HIMSS Conference, February 22-26, 1998, Orlando, Florida, Volume 3  (pp. 121-131). Chicago, IL: HIMSS.

317.    Howard, P. A., Weinhold, F. E., & May, S. G. (1998). Assessment of a critical pathway for the therapeutic management of Q- wave myocardial infarction. Hospital Pharmacy, 33(6), 682-697.
Abstract: At our institution, a critical pathway for Q-wave myocardial infarction was developed by a multidisciplinary team that included clinical pharmacists. The goal was to provide standardized, optimal care based on current clinical trial evidence and management guidelines. After implementation of the pathway, we conducted a pilot study to determine its impact on drug utilization patterns and patient outcomes. Using both retrospective and prospective medical chart reviews, we studied 39 patients: 25 patients admitted prior to, and 14 patients admitted after, implementation of the pathway. Overall, use of the critical pathway resulted in trends toward increased utilization of drugs known to reduce morbidity and mortality following acute myocardial infarction, fewer in-hospital complications, increased survival, and decreased length of stay. A regression analysis showed that the only independent predictor of length of stay was use of the critical pathway. The small sample population in this study precludes definitive conclusions; however, the study demonstrates the potential value of an ongoing quality-assurance program for evaluating the effectiveness a critical pathway.  [References: 24]

318.    Heaney, D. C., Shorvon, S. D., & Sander, J. W. (1998). An economic appraisal of carbamazepine, lamotrigine, phenytoin and valproate as initial treatment in adults with newly diagnosed epilepsy. Epilepsia, 39(Suppl 3), S19-S25.
Abstract: We undertook an economic appraisal of four drugs used in monotherapy during the first 2 years of treatment for newly diagnosed patients with epilepsy: carbamazepine (CBZ), lamotrigine (LTG), phenytoin (PHT), and valproate (VPA). We adopted the cost-minimization model because, although no single trial compares all four drugs directly, the clinical trials comparing two or more of these drugs in newly diagnosed cases show no significant difference in efficacy between the drugs in terms of seizure frequency. Considered in the cost analyses were frequency of side effects, retention rates, medical consultations, inpatient and accident and emergency costs, laboratory investigations, and drug changes. A Delphi panel provided the treatment pathways, including frequency of clinical consultations, second-line monotherapy, and side-effects management. A sensitivity analysis was performed, varying the assumptions on which the calculations were based. Analysis was completed for a prospective, intention-to-treat perspective and also for those patients continuing the initial drug. The direct medical costs of 2-years therapy (intention-to-treat analysis) calculated for each trial were pound sterling 795-829 for CBZ, pound sterling 1,525-2,076 for LTG, pound sterling 736-768 for PHT, and pound sterling 868-884 for VPA. A sensitivity analysis provided similar relative estimates. We found that LTG for newly diagnosed patients is significantly more expensive in direct health service costs incurred. This analysis incorporated seizure control, side effects, and tolerability. We recommend that a similar type of analysis be considered as part of all clinical trials of antiepileptic drugs in which efficacy of outcome is similar as a guide to assess optimal cost effectiveness

319.    Gavryck, W., Balder, A., Fischel, S., Grunwald, E., Krupnik, S., & Ryzewicz, S. (1998). Use of a clinical pathway in the recognition and treatment of alcohol withdrawal in a general hospital setting.  Journal of Addictive Diseases, 17(2), 148.

320.    Farrell, K. (1998). Critical/care pathways . In A. Luggen (Ed.), NGNA core curriculum for gerontological advanced practice nurses (pp. 160-162). Thousand Oaks, CA: Sage Publications.

321.    Dolan, S., & Olive, D. (1998). The importance of outcome assessment and continuous quality improvement in reproductive medicine. Infertility & Reproductive Medicine Clinics of North America, 9(1), 71-83.
Abstract: This article reviews theories of quality and advocates a model of continuous quality improvement. It proposes that behavioral outcomes are the central outcomes in health care and addresses measures of 'QQL.' The theory of evidence-based medicine is explained and illustrated. As tangible examples of outcome assessment and continuous quality improvement, clinical pathways and criteria sets are presented.  [References: 18]

322.    Dixon, P. S., & Prior, M. (1998). Clinical pathways and treatment algorithms in oncology patients: 'Not bad' but are they beneficial? Seminars in Oncology, 25(3), xiii-xix.

323.    Court, D., Loupus, D., & Morrison, S. (1998). CarePaths: A tool for coping with managed care. Topics in Spinal Cord Injury Rehabilitation , 3(4), 44-52.
Abstract: The standardization of care and projection of clinical outcomes has become a necessity for ensuring an organization's viability in a managed care environment. CareMaps(TM), or CarePaths as we have chosen to call our tools, can be a valuable adjunct to interdisciplinary rehabilitation care. CarePaths are a criteria-based guide for a patient's progression through the program. Variances that occur during a patient's stay assist the staff in targeting key indicators that may predict better resource utilization. The use of CarePaths also increases staff efficiency in time spent in documentation.  [References: 4]

324.    Chao, Y. F., Wu, C. Y., & Huang, C. H. (1998). The development and evaluation of the critical pathway of total knee joint replacement. TZU CHI MED J, 10(4), 311-325.
Abstract: The purpose of the study was to establish the critical clinical pathway of total knee arthroplasty (TKA) for cost-effect management. We reviewed the medical charts, conducted clinical observations and consulted with orthopedic specialists (MDs) in one medical center to develop the TKA clinical pathway map. We applied the 'Critical Path Method' (CPM) to determine the critical pathway. The jobs on the critical pathway was: admission [right arrow] waiting for surgery [right arrow] TKA surgery [right arrow] requesting rehabilitation evaluation [right arrow] waiting for rehabilitation, doctor'evaluation [right arrow] waiting for walk training [right arrow] obtaining satisfactory activity level [right arrow] discharge. The average length of hospital stay (LOS) for a patient to complete the critical pathway for TKA (CPTKA) was 15 days. A table integrating the critical jobs of the CPTKA was developed and applied in the clinic to control the length of stay for TKA surgery patient for 3 months. A reduction of LOS from 20.2 days to 14.4 days was achieved. Based on the CPTKA, a reasonable cost for this procedure was established. The CPTKA is also expected to serve as a guideline for continuous quality improvement and cost control of TKA procedures in the clinical practice. We suggest that each hospital apply CPM to develop CPTKA and use the developed CPTKA to monitor and control the LOS. We also suggest that the CPTKA be revised yearly. By this doing, a continuous improvement in quality and cost control will be obtained.  [References: 16]

325.    Chang, P. L., Huang, S. T., Wang, T. M., Hsieh, M. L., & Tsui, K. H. (1998). Improvement of medical care quality after implementation of a clinical path monitoring program for transurethral prostatectomy patients. European Urology, 33(6), 523-8.
Abstract: OBJECTIVES: The purpose of this study was to determine the effect on quality of care through the implementation of a clinical path for patients receiving transurethral prostatectomy. METHODS: We selected ten quality indicators with important clinical relevance as representative elements of the clinical path. These quality indicators were monitored during the entire hospitalization period of 100 consecutive patients who received transurethral prostatectomy. Monitoring data obtained from these patients were compared to data from 100 patients who received transurethral prostatectomy prior to implementation of the clinical path. Data was assessed to determine the relationship between quality indicators and management processes. RESULTS: Implementation of the clinical path for transurethral prostatectomy significantly decreased the percent of patients with incomplete preoperative tests on admission day, the duration of intravenous antibiotics administration, the percent of patients who required acute pain management postoperatively, the percent of patients who received postoperative bladder irrigation with normal saline and the percent of patients who had their Foley catheter removed after postoperative day 2. Three of the quality indicators had a significant relationship with management processes and may have directly affected the total admission charges. CONCLUSIONS: To evaluate the effect of the transurethral prostatectomy clinical path implementation on the quality of medical care, we compared ten quality indicators before and after implementation of this path. We concluded that implementation of the clinical path resulted in a statistically significant improvement in the quality of medical care

326.    Broder, M. S. (1998). Early experiences with a clinical pathway for hysterectomy and myomectomy. J GYNECOL TECH, 4(2), 55-59.
Abstract: Objective: To determine if improved postoperative care for women having hysterectomy and myomectomy can be achieved through the use of a clinical pathway. Methods: A team-based, cooperative approach to developing a clinical pathway was guided by data from the literature and from patient focus groups. The pathway was gradually implemented over several months. A case-control comparison of administrative data from patients cared for using the pathway in its first 3 months was performed. Results: Pathway development was a cooperative process involving a multidisciplinary team. Patient focus groups helped guide the development process. Pathway orders were evidence-based to the greatest extent possible. Residents and faculty became increasingly comfortable using the pathway over time. Both costs and charges were significantly decreased for patients on the clinical pathway. Charge reductions came predominantly from room and nursing care, pharmacy, and clinical laboratories. Use of the clinical pathway resulted in no significant decrease in length of stay. Conclusion: Clinical pathways can reduce the cost and charges associated with postoperative care of women having hysterectomy and myomectomy. The mechanism of this cost reduction may be independent of shorter length of stay. A team approach and a focus on patient concerns during pathway development may ensure that quality improvement, rather than simply cost reduction, arises from the use of clinical pathways.  [References: 17]

327.    Brewer, T. G., Genovese, R. F., Newman, D. B., & Li, Q. (1998). Factors relating to neurotoxicity of artemisinin antimalarial drugs "listening to arteether". [Review] [20 refs]. Medecine Tropicale, 58(3 Suppl), 22-7.
Abstract: The discovery of the occult brainstem neurotoxicity subsequent to widespread deployment of artemisinin derivatives has created particular problems. That is, the clinical setting for artemisinin use is problematic for accomplishing what ordinarily would be addressed in phase I-II clinical trials. Nevertheless, it is clear that an urgent and vital need exists for the deployment and widespread availability of artemisinins. The work done to date has already yielded a substantial body of evidence that, while incomplete, provides guidelines for artemisinin use to minimize the risk of these drugs while preserving their much-needed efficacy. The evidence thus far shows that route of administration, oil/water solubility and concentration-duration of drug level, are critical determinants of toxicity and can be given appropriate consideration in the clinical decisions regarding route, choice of drug used, and drug regimens. In this regard, an oral, water-soluble drug with moderately rapid clearance may be the most attractive choice in the absence of significant differences in efficacy. The same body of evidence clearly shows that toxicity can, and does, develop with no obvious or useful clinical marker. Therefore, the development and validation of a test that can reliably detect the onset of injury, at a reversible stage, is a critical path task for any future development in this class. More complete understanding of mechanisms, kinetics, and molecular targets of neurotoxicity, will certainly be forthcoming. A continuing, more generalized use of these drugs, however, cannot be fully endorsed without a useful, practical clinical test of toxicity. The requirement is especially critical in light of the reality that those patients receiving artemisinin derivatives live in high risk environments and are likely to receive repeated courses of therapy with little likelihood of close, post marketing surveillance. [References: 20]

328.    Bosch, X., Lee, T. H., & Nichol, G. (1998). Critical pathway for chest pain [1]. Annals of Internal Medicine, 129(1), 70.

329.    Ellrodt, A. G., Cho, M., Cush, J. J., Kavanaugh, A. F., & Lipsky, P. E. (1997). An evidence-based medicine approach to the diagnosis and management of musculoskeletal complaints. [Review] [33 refs]. American Journal of Medicine, 103(6A), 3S-6S.
Abstract: Evidence-based medicine is an approach to clinical practice and teaching that emphasizes decision-making based on rigorous analysis of clinical research tailored to the individual characteristics of a specific patient. As such, it can be considered the scientifically grounded art of medicine. Through evidence-based guidelines, pathways, and algorithms, the care of populations of patients may also be facilitated by informing individual practitioners of optimal decision-making in specific situations or providing the foundation for comprehensive "disease management" programs. These programs coordinate care for patients with chronic conditions, such as rheumatoid arthritis and osteoarthritis, across time and multiple disciplines. We present an approach to the development of decision-making aids, including guidelines and algorithms, which should be helpful in the care of individual patients and populations for whom physicians and other healthcare practitioners are responsible. [References: 33]

330.    Dadd, D. (1997). Management. Implementing a new clinical pathway system. Nursing Spectrum (New York/New Jersey Metro Edition), 9A(25 New Jersey Ed), NJ4.

331.    Nichol, G., Walls, R., Goldman, L., Pearson, S., Hartley, L. H., Antman, E., Stockman, M., Teich, J. M., Cannon, C. P., Johnson, P. A., Kuntz, K. M., & Lee, T. H. (1997). A critical pathway for management of patients with acute chest pain who are at low risk for myocardial ischemia: recommendations and potential impact [see comments]. Annals of Internal Medicine, 127(11), 996-1005.
Notes: Comment in: Ann Intern Med 1998 Jul 1;129(1):70-1
Abstract: BACKGROUND: Use of resources for patients with acute chest pain may be improved with clinical strategies that integrate research, Bayesian analysis, and expert opinion. OBJECTIVES: To 1) develop a critical pathway for management of patients with acute chest pain who are at low risk for complications of ischemic heart disease and 2) assess the potential effects of implementation of the pathway on patient safety and resource use. DESIGN: Evidence-based consensus and prospective cohort study. SETTING: Urban teaching hospital. PATIENTS: Patients at least 30 years of age who were seen in the emergency department for chest pain and who did not have a history of trauma or abnormalities on radiologic study. INTERVENTION: Physician-opinion leaders defined criteria for patient inclusion in the pathway and for remaining on the pathway after 6 or 12 hours of observation. Criteria were defined for appropriateness of direct admission, direct discharge, or 6 hours of observation followed by exercise treadmill testing. MEASUREMENTS: Number of patients admitted to the hospital, number of days that patients were hospitalized, and clinical outcome. RESULTS: 2898 of 4585 patients (63%) were admitted to the hospital; of the 2898, 1152 (40%) were classified as potentially eligible for the pathway and 1068 (93%) had a benign clinical course during the initial observation period. The 1068 patients had a mean length of stay of 2.8 +/- 4.8 days. If 47% of these patients had been discharged after observation and exercise testing, implementation of the pathway would have reduced the number of admissions by 505 (17%) and days of hospitalization by 1407 (11%). CONCLUSIONS: Retrospective analysis suggests that a critical pathway for patients with acute chest pain may substantially reduce resource use. Prospective study is needed to ensure increased efficiency without increased adverse outcomes

332.    Zevola, D. R., Raffa, M., Brown, K., Hourihan, E. C., & Maier, B. (1997). Clinical pathways and coronary artery bypass surgery. [Review] [17 refs]. Critical Care Nurse, 17(6), 20-33; quiz 34-5.
Abstract: Use of a multidisciplinary clinical pathway helps eliminate variations in patients' care. Organizing the care delivered each day of the patient's hospitalization may lead to fewer complications, a quicker recovery, and an earlier discharge. In today's healthcare arena, much attention is being focused on improving the quality of care and decreasing the need for acute care. Clinical pathways facilitate patients' outcomes and earlier discharge and thus reduce the cost of care. [References: 17]

333.    Weiland, D. E. (1997). Why use clinical pathways rather than practice guidelines? American Journal of Surgery, 174(6), 592-5.
Abstract: BACKGROUND: Financial pressures from managed care organizations, the government, and other "stakeholders" have resulted in the production of practice guidelines and clinical pathways. Clinical pathways involve all segments of a health care system and may prove to be more beneficial and less hazardous to patients and health care providers. METHODS: A historical narrative describing the development of clinical pathways by the Southwestern Surgical Congress (SWSC) and the Southeastern Surgical Congress (SESC) is made. The motivations, the benefits, and the hazards of both clinical pathways and practice guidelines are discussed. RESULTS: Clinical pathways have proven to reduce length of stay (LOS), complications, and cost, and provide increased patient satisfaction whereas practice guidelines from some specialties show improved quality of care when compared with nonspecialists. However, many practice guidelines are developed by specialists on "best practice" standards, and few have documented studies proving their effectiveness. CONCLUSIONS: Eleven clinical pathways were developed by the SWSC and the SESC and are in the process of revision and study for efficacy. They will be disseminated in the American Surgeon and on the SWSC web site for review and comment. In 1998, both congresses hope to publish the efficacy of selected pathways by describing their effect on LOS and charge for those diagnostic-related groups

334.    Smith, N. (1997). High hopes: better care for young families. Hmo Practice, 11(4), 179-81.

335.    Rosenstein, A. H. (1997). Healthcare resource management: integrating apples and oranges. Journal of Healthcare Resource Management, 15(10), 10-7.
Abstract: Over the past several years this journal has published numerous articles on the merits and benefits of effective resource management. Independently, these articles have supported the value of effective supply and materials management, management engineering and system restructuring, and clinical resource management in being able to save healthcare dollars by designing and injecting efficiencies into the healthcare delivery system. While most of these resource management activities have utilized very similar strategies (see Table 1 "Tools For Improvement"), much of the process revision and progress has remained within the walls of their own individual disciplines. Any widescale attempts to try to fully integrate all of these activities have been hampered by the intricacies of trying to mix apples and oranges. Despite these individual departmental gains, the challenge to conserve healthcare costs continues to permeate throughout all levels of the organization, and institutions are finally beginning to recognize the added value of merging these activities into a more centralized coordinated approach to resource management. Presented is a discussion on the potential value of developing a well-focused, integrated resource management program.  (Abstract by: Author)

336.    Rapp, K., Bratina, P., Barch, C., Braimah, J., Daley, S., Donnarumma, R., Kongable, G., Sailor, S., & Spilker, J. (1997). Code Stroke: rapid transport, triage and treatment using rt-PA therapy. The NINDS rt-PA Stroke Study Group. [Review] [10 refs]. Journal of Neuroscience Nursing, 29(6), 361-6.
Abstract: With the approval of rt-PA therapy for ischemic stroke, stroke care has acutely transitioned from focusing on rehabilitative services to emergency services. This treatment, which must be initiated within the first three hours after the onset of stroke symptoms, requires reorganization of current management approaches. Developing a Code Stroke Team facilitates this process and helps to identify potential thrombolysis candidates. A pathway to deliver rapid care begins with 911 notification and transport, emergency department triage and procedures, and moves through the initiation of thrombolytic therapy. We call this pathway "Code Stroke". [References: 10]

337.    Olds, S. (1997). Designing a care pathway for a maternity support service program in a rural health department. [Review] [20 refs]. Public Health Nursing, 14(6), 332-8.
Abstract: Today's heath care system in the United States faces many financial dilemmas related to the country's current economic status. Despite dwindling resources, the health care system must continue to provide high quality care to meet ever-increasing demands (Ferguson, 1993). Care pathways are an example of case management tools which provide care coordination. With an interdisciplinary approach, pathways increase communication and continuity of care between service disciplines, as well as improve efficient resource utilization. The purpose of this paper was to review: (1) the literature related to the benefits of using care pathways to enhance client care; (2) the benefits of public health nurse home visitation to pregnant and postpartum women; and (3) to describe the process to design a care pathway for the Maternity Support Service (MSS) program at a rural health department. This health department provides MSS to a county with a population of 65,000, with over 900 births per year. The county is 100 miles wide and 28 miles long. Thus, the MSS staff cover a large area, and needed a method to maximize efficient use of staff time. Care pathways have tremendous appeal because they accommodate interdisciplinary teams of care, focus on process, reduce unnecessary variation in care, and attend to quality and client outcomes. [References: 20]

338.    Mabrey, J. D., Toohey, J. S., Armstrong, D. A., Lavery, L., & Wammack, L. A. (1997). Clinical pathway management of total knee arthroplasty. Clinical Orthopaedics & Related Research, (345), 125-33.
Abstract: Using a retrospective cohort study design, the authors examined complications, readmissions, morbidity and mortality, and function scores in two groups of patients attended by the same surgeon for the year before and the year after the implementation of an outcomes management program with clinical pathways for patients undergoing total knee arthroplasty at an academic health center. The effectiveness of the pathway constantly was adjusted using variance analysis and continuous quality improvement techniques. This program reduced the length of stay by 57% from a premanagement value of 10.9 +/- 5.4 days in 1994 (Group 1) to 4.7 +/- 1.4 days in 1996 (Group 2). Hospital costs (based on an inflation adjusted cost to charge ratio) for all total knees were reduced 11% from $13,328 +/- $3905 in 1994 to $11,862 +/- $4763 in 1996. Preoperative and postoperative knee scores were 41.1 +/- 16.3 and 84.2 +/- 16.0 for Group 1 and 42.5 +/- 13.0 and 87.0 +/- 10.4 for Group 2, respectively. There was no statistically significant difference between the preoperative or the postoperative knee scores of Groups 1 and 2. The application of clinical pathways, variance analysis, and continuous quality improvement toward the treatment of patients who had total knee arthroplasty at an academic health center resulted in significant savings in length of stay without adversely affecting overall outcome

339.    Lawson, M. J., Lapinski, B. J., & Velasco, E. C. (1997). Tonsillectomy and adenoidectomy pathway plan of care for the pediatric patient in day surgery. Journal of Perianesthesia Nursing, 12(6), 387-95.
Abstract: The care of children undergoing tonsillectomy and adenoidectomy (T&A) in the day surgery setting can be costly, due in a large part to the length of stay after surgery. A clinical pathway standardizes the length of stay and, therefore, directly controls costs associated with outpatient T&A. A T&A pathway plan of care was developed at one institution to (1) decrease the cost of the procedure, (2) improve parent/patient satisfaction, and (3) maintain or improve the quality of care

340.    Homes, L. M., & Hollabaugh, S. K. (1997). Using the continuous quality improvement process to improve the care of patients after angioplasty. Critical Care Nurse, 17(6), 56-65.

341.    Enterline, J. (1997). Care across the continuum: CHF demonstration project. Developing a regional model for disease management. Hospital Case Management, 5(12), 219-22.

342.    Cushing, K. A., & Stratta, R. J. (1997). Design, development, and implementation of a critical pathway in simultaneous pancreas-kidney transplant recipients. Journal of Transplant Coordination, 7(4), 164-72.
Abstract: The purpose of this study was to assess the effect of implementation of a critical pathway after simultaneous pancreas-kidney transplantation on length of stay and hospital charges. Two well-matched groups were compared: 10 patients who received transplants in 1991 (before implementation of the critical pathway) and 10 patients who received transplants in 1995 (after implementation). For the initial transplant hospitalization, the critical pathway was associated with significant reductions in length of stay, total number of laboratory tests, clinical laboratory charges, and total inpatient charges with organ acquisition charges excluded. Despite the rising costs of medical care, we have designed and implemented a critical pathway for simultaneous pancreas-kidney transplantation that has stabilized hospital charges by decreasing length of stay and the number of clinical laboratory tests

343.    Burns, S. M., Daly, B., & Tice, P. (1997). Being led down the critical pathway: a perspective on the importance of care managers vs critical pathways for patients requiring prolonged mechanical ventilation. [Review] [40 refs]. Critical Care Nurse, 17(6), 70-5.

344.    Braimah, J., Kongable, G., Rapp, K., Daley, S., Bratina, P., Sailor, S., Barch, C., Donnarumma, R., & Spilker, J. (1997). Nursing care of acute stroke patients after receiving rt-PA therapy. The NINDS rt-PA Stroke Study Group. [Review] [18 refs]. Journal of Neuroscience Nursing, 29(6), 373-83.
Abstract: Treatment with tissue plasminogen activator (rt-PA) for acute stroke requires intensive care of the patient. The risk of thrombolytic therapy and the need for rapid interventions make it clear that the nursing role during this time is crucial. Nurses should be familiar with safe dosage and administration of rt-PA for stroke, which is clearly different than administration of rt-PA for myocardial infarction. Furthermore, thrombolytic stroke treatment must be accompanied by intensive neurological monitoring to observe for complications. Intracerebral hemorrhage is usually accompanied by an acute change in neurological status and vital sign instability. Intensive monitoring of neurologic condition, vital signs, cardiac status and other standard critical care practices must be initiated immediately to optimize patient outcome. [References: 18]

345.    Barch, C., Spilker, J., Bratina, P., Rapp, K., Daley, S., Donnarumma, R., Sailor, S., Braimah, J., & Kongable, G. (1997). Nursing management of acute complications following rt-PA in acute ischemic stroke. The NINDS rt-PA Stroke Study Group. [Review] [18 refs]. Journal of Neuroscience Nursing, 29(6), 367-72.
Abstract: In the National Institutes of Neurologic Disorders and Stroke (NINDS) recombinant tissue plasminogen activator (rt-PA) stroke trial, the primary adverse events monitored were intracranial hemorrhage (ICH), systemic bleeding, death and new stroke. Nurses caring for the study patients noted these adverse events and other complications. In addition to what is known about acute ischemic stroke (AIS), the NINDS trial provides further information for optimal care of this specific group of patients. The complications found in this trial require expert nursing care to monitor, prevent and intervene, making clinical decisions relevant to the patients needs. The critical decision-making process must be grounded in knowledge of acute stroke physiology and thrombolysis. [References: 18]

346.    Ellrodt, G., Cook, D. J., Lee, J., Cho, M., Hunt, D., & Weingarten, S. (1997). Evidence-based disease management. JAMA, 278(20), 1687-92.
Abstract: Disease management is an approach to patient care that emphasizes coordinated, comprehensive care along the continuum of disease and across health care delivery systems. Evidence-based medicine is an approach to practice and teaching that integrates pathophysiological rationale, caregiver experience, and patient preferences with valid and current clinical research evidence. Using diabetes mellitus as an example, we describe the importance of evidence-based medicine to the development of disease management programs. We present a method for developing and implementing evidence-based clinical guidelines, clinical pathways, and algorithms and describe the creation of systems to measure and report processes and outcomes that could drive quality improvement in diabetes care. Multidisciplinary teams are ideally suited to develop, lead, and implement evidence-based disease management programs, since they play an essential role in the preventive, diagnostic, and therapeutic decisions for patients with diabetes throughout the course of their disease

347.    Talley, J. W., & Sleeper, P. M. (1997). Roadblocks to the implementation of biotreatment strategies. Annals of the New York Academy of Sciences, 829, 16-29.
Abstract: The Department of Defense (DoD) has over 21,000 contaminated sites requiring some form of remediation. Contaminants on these sites include explosive compounds (i.e., TNT, RDX, HMX), chlorinated solvents (i.e., PCE, TCE, TCA), polycyclic aromatic hydrocarbons (i.e., benzo-a-pyrene), and polychlorinated biphenyls (i.e., aroclors). Current technology has centered around incineration, air stripping, and the use of activated carbon. Frequently, this technology is not cost effective nor publicly acceptable. Biotreatment offers a possible alternative. Biotreatment can cost effectively eliminate contaminants and avoid the use of harsh chemicals and physical treatments. However, special care must be employed to ensure that the proper remediation system is designed and engineered to optimize clean-up and minimize costs. Unfortunately, not all bioremediation efforts have been successful. In an attempt to develop bioremediation technology from the flask (bench scale) to the field (full-scale design), many scientists and engineers have failed to understand the phenomena that influence bioremediation. Issues such as additional mass transport mechanisms/limitations, the presence of multiple phases, spatial heterogeneities, and unfavorable factors for bacterial growth represent only a few of the phenomena that can limit or complicate biodegradation. Successful bioremediation requires a complete examination of the phenomena that can be observed as the scientist and engineer progress together from the bench to the field. An excellent way to examine these phenomena is by using the conceptual scales of observation: microscale, mesoscale, and macroscale. The microscale represents the level at which chemical/microbial species and reactions can be characterized independently of any transport phenomena. These activities are those occurring at the microbial cell level and generally are the focus of bench level work. The mesoscale is the level at which transport phenomena and system geometry are first apparent, with the exclusion of advective or mixing processes. This scale represents those activities that occur at the pore channel, soil particle or microbial aggregate level. The macroscale is the scale at which you have the ability to discern advective or mixing phenomena. These activities are generally associated on a site level and are the focus of the design engineer. The critical path as bioremediation technology is developed from flask to field is to observe and understand the phenomena that exert influence at each scale of observation so that its effects can be incorporated into the final remediation design

348.    Petro, J. A., Tack, C. M., & Groh, J. (1997). Up close & clinical. A critical pathway for organ donation: one possible solution to a crucial need. Nursing Spectrum (Greater Philadelphia/Tri-State Edition), 6(22), 10-1.

349.    Tombes, M. B. (1997). Practice corner. Practice tips from Massey Cancer Center, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA. Oncology Nursing Forum, 24(10), 1681-1685.

350.    Olson, V., Coyne, P., Smith, V., & Hudson, C. (1997). Critical pathway improves outcomes for patients with sickle-cell disease. Oncology Nursing Forum, 24(10), 1682.

351.    Nichols, D., & Zallar, M. J. (1997). Care coordination: a new role in a customer-focused healthcare system. Nursing Case Management, 2(6), 269-74.
Abstract: In the current healthcare environment, all healthcare providers are challenged to provide quality patient care in an efficient, cost-effective manner. Managed care organizations and third-party payors actively collect data related to cost, length of stay, resource use, and patient outcomes for use in affiliating and contracting with healthcare facilities and providers. The authors, in this article, outline one organization's evolution from a "utilization review"-based discharge planning process to a proactive "utilization management" approach to care coordination.  (1 ref)

352.    Murphy, M. P., Martin-White, S., Peters, S., & DeHope, E. (1997). Critical pathways in rehabilitation. Case Manager, 8(6), 65-8.

353.    McGinty, J. (1997). Look at cost savings and care paths with an ethical eye. Nursing Case Management, 2(6), 267-8.

354.    Martinez, K. E., & Moore-Koehler, K. (1997). Poisoning and toxic effects of drugs: a critical pathway for improving outcomes. Pediatric Nursing, 23(6), 609-12.
Abstract: Increasing cost constraints and the continuous need to enhance quality has focused attention on developing and implementing programs to improve patient care delivery. Case management programs enable organizations to balance quality components with costs to improve outcomes for patient populations. Critical pathways can be utilized as a tool for promoting optimal outcomes for case managed populations in acute care hospitals

355.    Kreiss, J. L., & Patterson, D. L. (1997). Psychosocial issues in primary care of lesbian, gay, bisexual, and transgender youth. [Review] [21 refs]. Journal of Pediatric Health Care, 11(6), 266-74.
Abstract: Lesbian, gay, bisexual, and transgender youth are at risk for a multitude of physical, emotional, and social health problems. During the past decade it has been well documented that these youth have higher-than-average rates of depression, suicide attempts, substance abuse, sexually transmitted diseases, school failure, family rejection, and homelessness. The focus of this article is to outline skills and strategies that can assist the health practitioner in creating an optimal health care experience for sexual minority youth. Models of individual and family adaptation, a clinical path, and a referral list are presented. Current health care delivery sites are examined, and recommendations are given for improvement of both practitioner skills and health care programs targeting these youth. [References: 21]

356.    Hoey, J. P., & Soehl, S. (1997). Care maps, utilization, and outcomes: a viable solution. Journal of Oncology Management, 6(6), 29-32.
Abstract: Clearly, the changing healthcare environment and specific forces confronting cancer therapy today are necessitating collection and analysis of utilization, cost, and outcomes information. Manual tracking of information or tracking through multiple, disparate computer systems are cost--prohibitive alternatives to enabling cancer centers to efficiently and effectively manage these sophisticated information needs. However, the implementation of a cancer-therapy management system, which includes a disease-based process model of treatment and facilitates data-collection at the point of care, is now a strategic imperative for healthcare organizations.  (Abstract by: Author)

357.    Ellershaw, J., Foster, A., Murphy, D., Shea, T., & Overill, S. (1997). Organisation of services. Developing an integrated care pathway for the dying patient. European Journal of Palliative Care, 4(6), 203-7.
Abstract: John Ellershaw, Alison Foster, Deborah Murphy, Tom Shea and Susan Overill explain and illustrate the development of multidisciplinary care pathways in palliative care.  (18 ref)

358.    Courtney, L., Gordon, M., & Romer, L. (1997). A clinical path for adult diabetes. Diabetes Educator, 23(6), 664-71.
Abstract: The use of clinical paths for patient care management was explored by this development team as a mechanism to provide consistent, high-quality care to hospitalized patients in high-volume, high-risk diagnostic categories. Reviewing the historical aspects and importance of clinical paths helped expand the team's perspective to incorporate pre- and posthospitalization phases of patient care into the clinical path being developed. A multidisciplinary team of physicians, nurses, health educators, and dietitians from both inpatient and outpatient departments of Kaiser-Santa Teresa Medical Center in San Jose, California, devised and implemented an Adult Diabetes Mellitus care path. Staff education preceded the implementation of the care paths. Measurements of quality indicators showed improvements in patient satisfaction, patient education, patient knowledge, and nutrition assessments

359.    Brunner, L., & Hickey, M. E. (1997). Disease management: Lovelace Health Systems episodes of care -- a case study. Best Practices & Benchmarking in Healthcare: a Practical Journal for Clinical & Management Applications, 2(6), 254-7.
Abstract: The evolving paradigm shift in healthcare emphasizes population health status. Disease management is gaining popularity as a means of providing cost-effective, quality healthcare to an entire population at risk. Outcomes measurements, standardized clinical protocols and commitment by physicians and staff are crucial to a successful program. This article presents a case study from Lovelace Health Systems in Albuquerque, N.M., and identifies key components, cost savings and successes of one of its disease management programs.  (5 ref)

360.    Bonfiglio, M. F., Lewis, J. D., Nesbit, S. A., & Krinsky, D. L. (1997). A contemporary perspective on pharmacy's traditional strengths. Journal of the American Pharmaceutical Association, NS37(6), 700-4.
Abstract: OBJECTIVE: To present a framework for recognizing, appreciating, and applying the specific skills used during the processes of medication order screening and therapy monitoring in daily practice. SUMMARY: The health care system in which the profession of pharmacy serves is undergoing significant change. The profession is continually reacting to this change. Recently these reactions have included a shift in focus from the medication order processing skills all pharmacists possess to such things as medication prescribing, clinical pathway development, and formulary management. Although some of these activities have merit, we believe that the disregard of pharmacy's traditional strengths applied to medication order processing may damage both patient care and the system in which we practice. Renewed focus must be applied to the development of practice models that include the application of unique pharmacist skills (e.g., optimizing drug doses, safety, routes of administration, and compliance) as integral components. Variances in knowledge and training among pharmacists may result in differences in the level of service provided to a given patient. However, all pharmacists are equipped to provide unique professional services at a level that has demonstrable impact on patient care. CONCLUSION: Pharmacists are uniquely skilled in ensuring the safe and effective use of medications. The authors believe that the specific skills applied during the processes of medication order screening and therapy monitoring can and should be incorporated into daily practice. Failure to do so will deprive patients of optimal care and pharmacists of professional satisfaction. We encourage pharmacists to recognize and develop their unique, traditional strengths, and subsequently allow these strengths to provide the health benefits for which they were intended

361.    Wilson, J. (1997). Integrated care management. Nursing Management, 4(7), 18-9.

362.    Waters, E. (1997). Improving clinical effectiveness: a practical approach. Journal of Evaluation in Clinical Practice, 3(4), 255-64.
Abstract: The publication of the government white paper 'Working for Patients' (1989, HMSO) and implementation of subsequent NHS reforms has led to the development of a great number of initiatives designed to improve the quality of patient care and to make the provision of care more clinically and cost effective. Many of these initiatives, whilst laudable, have been developed in isolation and often without proper consideration of how they relate to one another or might practically be implemented throughout the NHS. It has commonly been the case that attempts to transfer the initiative from an environment of high enthusiasm and, often, high resource to the NHS in general has either failed or led to poor application. Strategies to improve clinical effectiveness have not become a feature of the everyday practice of many, let alone most or all, clinicians in the NHS. The result has been their failure significantly to raise standards of care across the NHS as a whole. It is suggested that many of the initiatives are closely related, and more effective implementation in the NHS as a whole may follow attempts to integrate them in a more practical approach to care management within an organization-wide clinical effectiveness strategy. It is further suggested that this is best achieved by a continuous quality improvement approach focusing on the care process as the centrepiece of the initiative, and that this method will lead to significant improvements not only in clinical effectiveness but also in cost effectiveness. This paper describes a proposed method of achieving these goals

363.    McCoy, K. S., Stokes, D., Dubroff, M., Hoffman, A., Mischler, N. E., & Erickson, S. (1997). Managed care and the cystic fibrosis patient. [Review] [19 refs]. Current Opinion In Pulmonary Medicine, 3(6), 425-9.
Abstract: Since the first published report of mortality in cystic fibrosis in 1969, the median survival among cystic fibrosis patients has risen from 14 to 31 years. The reasons for this improved survival are complex and include earlier diagnosis; improved control of pulmonary infection; aggressive nutritional intervention; and enhanced monitoring of patients in peer-reviewed, accredited centers for cystic fibrosis care, teaching, and research. Emphasis on the importance of research on changing and improved treatment has been effectively communicated to patients and families. As a result, a group of highly educated medical consumers has been created. During the last decade, another focus of rapid change has appeared, that of cost containment in the medical profession, creating the field of managed care. Practicing medical professionals perceive the need for reduction in excessive spending in medicine and have taken a variety of approaches to balance better the value and cost of medical care while maintaining superb quality. Physicians and consumers continue to have concerns about the potential negative impact of managed care on a relatively rare, specialized, and chronic illness such as cystic fibrosis if managed care concepts are applied without proper understanding of the disease. A great concern is that managed care in cystic fibrosis may cause reversal of trends in improved quality and length of survival. The increased length of survival places an increasing demand on the already stressed system of health care financing. Understanding the changing area of managed care is therefore of paramount importance to clinicians involved in cystic fibrosis care. The Cystic Fibrosis Foundation has presented symposia on managed care at each of the last three annual meetings, including the North American Cystic Fibrosis Meeting, October 1996. The following issues were addressed by speakers and panel discussants, with portions excerpted for this review: trends in managed care, measures and guidelines useful in managed care, Medicaid managed care and cystic fibrosis, and practical aspects of using pathways in caring for patients with cystic fibrosis. [References: 19]

364.    McClung, L. T. (1997). Clinical pathways for the terminally ill. Caring, 16(11), 26-8, 30, 32.
Abstract: Clinical pathways help providers to enhance documentation, standardize care, and improve patient outcomes. One agency developed a clinical pathway that offers terminally ill patients comprehensive, accessible, and coordinated care. It prompts each team member to recognize positive outcomes and to conduct ongoing goal setting with the patient and family.  (Abstract by: Author)

365.    Manning, C. (1997). Critical path network. Carotid endarterectomy path cuts LOS below two days. Hospital Case Management, 5(11), 199-202,208.

366.    Manning, C. (1997). Carotid endarterectomy path cuts LOS below two days. Hospital Case Management, 5(11), 199-202.

367.    Haugh, R. (1997). Carotid path breaks trail for other procedures. Or-Manager, 13(11), 32.

368.    Godchaux, C. W., Travioli, J., & Hughes, L. A. (1997). A continuum of care model. Nursing Management, 28(11), 73-6.
Abstract: An interdisciplinary documentation tool provides a composite of all of the planning activities that occur relative to each individual patient and his/her family before discharge. In response to the Joint Commission on Accreditation of Healthcare Organization's mandate, this tool evolved into a "Continuum of Care" model. Now, all disciplines maintain a patient's continuity of care

369.    Ehrenstein, A., Schweickert, R., Choi, S., & Proctor, R. W. (1997). Scheduling processes in working memory: instructions control the order of memory search and mental arithmetic. Quarterly Journal of Experimental Psychology, A, Human Experimental Psychology.  50(4), 766-802.
Abstract: Humans must often use working memory to execute processes one at a time because of its limited capacity. Two experiments tested where limits in access to working memory occur. Subjects searched a short-term memory set for one stimulus digit and performed mental arithmetic with another stimulus digit. In one experiment, they were told to carry out the mental arithmetic before the memory search and to make the arithmetic response first. In the other, they were instructed to perform the tasks in the opposite order. The overt responses were executed in the prescribed order. Moreover, the covert working memory processes were executed in the prescribed order, as revealed by a critical path network analysis of reaction times. Results are explained in terms of a double-bottleneck model in which central processes and responses are constrained to be carried out for one task at a time

370.    Cheah, T. S. (1997). Clinical pathways--a new paradigm in healthcare? [editorial]. Singapore Medical Journal, 38(11), 467-8.

371.    Baird, A. (1997). Clinical pathways: a road map to improving care: part II. Point of View, 35(3), 6-8.

372.    Spath, P. L. (1997). Pathways to nowhere. Hospitals & Health Networks, 71(19), 78-9.
Abstract: Early in the decade, health care discovered a powerful patient care management tool: the clinical path. Leaders in the field latched onto paths as the solution to cost and quality dilemmas, but they overlooked the importance of the underlying principles of quality management. Beyond Clinical Paths, a new book from American Hospital Publishing, focuses on the issues critical to successful quality improvement through clinical paths. The following excerpt by the book's editor, Patrice L. Spath, sets the stage for a new approach to clinical quality

373.    McCrea, C. (1997). Mind the gap [interview by Roger Bushby]. Nursing Standard, 12(2), 22-3.

374.    Schriefer, J., Urden, L. D., & Rogers, S. (1997). Report cards: tools for managing pathways and outcomes. Outcomes Management for Nursing Practice, 1(1), 14-9.
Abstract: An overriding concern of many health care providers is how to maintain quality in such a turbulent, cost-driven environment. It is essential for health care providers to determine the effectiveness of their care and to institute changes in practice to affect patient outcomes in a positive fashion. Determining the appropriate outcomes to measure and formatting the report in an easy-to-read manner with meaningful information is important for presentation to a variety of audiences. We describe a report card methodology for disseminating outcome information that can easily be adapted in other settings

375.   Frank, M. O., Batteiger, B. E., Sorensen, S. J., Hartstein, A. I., Carr, J. A., McComb, J. S., Clark, C. D., Abel, S. R., Mikuta, J. M., & Jones, R. B. (1997). Decrease in expenditures and selected nosocomial infections following implementation of an antimicrobial-prescribing improvement program. Clinical Performance & Quality Health Care, 5(4), 180-8.
Abstract: OBJECTIVE: To evaluate changes in antimicrobial use and expenditures and the rates of selected nosocomial infections due to resistant organisms associated with implementation of an antimicrobial-prescribing improvement program. DESIGN: Before-after trial comparing 1992 (pre-program), 1993 (a transition year), and 1994 (after full implementation of the program). SETTING AND PARTICIPANTS: Academic medical center, all patients and physicians. INTERVENTION: An antimicrobial-prescribing improvement program with prior approval requirement for use of restricted agents. MAIN OUTCOME MEASURES: Antimicrobial use and expenditures, rates of selected nosocomial infection marker events. RESULTS: Between 1992 and 1994, there were substantial decreases in antimicrobial use, from 158,107 to 137,364 defined daily doses, and in expenditures from $2,486,902 ($24.01 per patient day) to $1,701,522 ($18.49 per patient day). After adjusting for changes in purchase prices and census days, we estimated savings attributable to the program of $279,573 in 1993 and $389,814 in 1994. In addition, we found significant decreases between 1992 and 1994 in the rates of enterococcal bacteremia (.34 vs .16 events per 1,000 patient days; P = .016), selected gram-negative bacteremia (.26 vs .11; P = .015), methicillin-resistant Staphylococcus aureus colonization or infection (.66 vs .20; P < .0001), and Stenotrophomonas colonization or infection (.35 vs .17; P = .019). No significant change occurred in rates of nosocomial candidemia or Clostridium difficile toxin-positive diarrhea. Values for 1993 were intermediate between those of 1992 and 1994. CONCLUSION: Implementation of an antimicrobial-prescribing improvement program was associated with substantial savings in antimicrobial use and expenditures and significant decreases in rates of selected nosocomial infections due to resistant organisms.  (Abstract by: Author)

376.    Whipple, T. W., & Little, A. B. (1997). Variance analysis for care path outcomes management [published erratum appears in J Nurs Care Qual 1998 Feb;12(3):vii]. Journal of Nursing Care Quality, 12(1), 20-5.
Abstract: Variance analysis and monitoring procedures of clinical care path interventions and outcomes are discussed with the objective of modifying suboptimal care paths into optimal pathways. These critical care paths will contain value-added interventions that contribute significantly to the achievement of measurable outcomes. Care path variables are defined and measurement considerations are presented. Variance analysis procedures, measures, and uses are discussed that facilitate outcomes management and continuous quality improvement

377.    Visalli, H. (1997). Developing a best practice model for care of patients with polydipsia. Journal of Nursing Care Quality, 12(1), 53-62.
Abstract: Some psychiatric patients diagnosed with schizophrenia have a secondary diagnosis of polydipsia which is manifested by consuming excessive quantities of fluids, marked confusion, and disorientation. In most instances, these persons are less amenable to treatment and rehabilitative interventions due to the changes in cognitive and physical processes. A review of our own current practice found that we had a small group of polydipsia patients requiring a large amount of one-to-one staff time for little or no long-term benefit. Further, there was no uniform approach to identify, treat, and monitor outcomes for patients with polydipsia. A TQM team was assembled with the goal of identifying a protocol for assessing the presence of polydipsia and a care map for the treatment of confirmed cases. The outcome was the development of a care map using diagnostic procedures and interventions found in the professional literature and empirical data collected on site. A short pilot study revealed that a number of polydipsia patients on Clozaril along with other interventions were successfully discharged from the hospital

378.    Tyler, D. O. (1997). Activity progression in acute cardiac patients. [Review] [70 refs]. Journal of Cardiovascular Nursing, 12(1), 16-32.
Abstract: Progressive advancement of activity in cardiac patients is well documented in the literature. However, the concern in today's practice centers on balancing prudent progression of activity with a cost-effective delivery of care. This article presents a review of the literature, comparing the state of knowledge with current clinical pathway suggestions for activity therapy in various cardiac populations. An overview of the historical background and the physiological adaptations to bedrest, orthostasis, and exercise are described. Research documenting energy costs and cardiovascular responses to activities of daily living, such as bathing, toileting, and ambulating is also critiqued. Generalizability of research findings is examined, particularly regarding the heterogeneity of cardiac populations (i.e., effects of age, gender, multiple medications, comorbidity), and implications for practice are addressed. [References: 70]

379.   Sundaram, R. S. (1997). The chest pain care pathway at Gundersen-Lutheran Medical Center. Wisconsin Medical Journal, 96(10), 39-43.

380.    Spann, K. (1997). Health matters: nurses are essential. MEDSURG Nursing, 6(5), 253, 255.

381.    Saunders, R. (1997). Lumbar discectomy: practice analysis and care guide. Hospital Case Management, 5(10), 181-4.

382.    Rietz, C., Erickson, S., & Deshpande, J. K. (1997). Clinical pathways and case management in anesthesia practice: new tools and systems for the evolving healthcare environment. AANA Journal, 65(5), 460-7.
Abstract: Clinical care pathways and case management are strategies utilized by increasing numbers of hospitals to meet the challenges of capitated reimbursement and managed care. A clinical pathway is an outcome-focused tool used to define a multidisciplinary plan of care. A case manager coordinates patient care across an episode of illness or hospitalization. These tools and systems have great potential for use by nurse anesthetists in ensuring that high-quality anesthesia care is delivered in a cost-effective manner

383.    Page, U. S., & Washburn, T. (1997). Using tracking data to find complications that physicians miss: the case of renal failure in cardiac surgery. Joint Commission Journal on Quality Improvement, 23(10), 511-20.
Abstract: BACKGROUND: Health Data Research, Inc (HDR) develops, manages, and maintains clinical registries from physicians and hospitals, including the Merged Cardiac Registry. Quarterly reports indicate data that are inconsistent, out of range, or outside the norms found in other medical centers. CASE STUDY: In reports on cardiac surgery patients, HDR noted that for the 1992-1996 period, 3 of the 30 contributing centers experienced a significant increase in the incidence of moderate and severe renal failure. One of these three contributors gave HDR access to its detailed clinical database, and HDR ruled out most of the suspected causes for this increase in renal failure. A risk model for renal failure identified 20% of the patients to be at high risk. HDR then isolated a fast-track protocol as the culprit. One of the 30 contributing centers found that the protocol was associated with significant decreases in the intensive care unit (ICU) and hospital lengths of stay. However, as the severity of renal failure increased, charges, average length of stay, transfusions, and ICU times increased. At one of the three sites, after protocol changes were instituted in mid-1995 for the high-risk patients, the rate of renal failure reverted to below baseline levels. SUMMARY AND CONCLUSIONS: Analysis of run charts led to protocol changes for patients at high risk of renal failure, while retaining the positive outcomes associated with rapid extubation and shorter ICU stays for the remaining 80% of the patients

384.    Meyer, T. C. (1997). Clinical pathways offer route to optimal patient care. Wisconsin Medical Journal, 96(10), 38.

385.    Meyer, T. (1997). Clinical pathway for total knee replacement. Wisconsin Medical Journal, 96(10), 44-7.

386.    Mark, H., & Garet, D. E. (1997). Interpreting profiling data in behavioral health care for a continuous quality improvement cycle. Joint Commission Journal on Quality Improvement, 23(10), 521-8.
Abstract: OUTCOME MEASUREMENT SYSTEM: PsychSentinel, a symptom reduction measure, uses 20 diagnostically defined symptom checklists derived from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Symptoms are enumerated and are assigned weights on the basis of clinical significance, providing an overall assessment of symptom intensity. The availability of multisite benchmark norms makes possible the computation of observed-to-expected ratios. EXAMPLES OF THE CONTINUOUS QUALITY IMPROVEMENT CYCLE: Six examples, drawn from the experience of a number of behavioral health care programs since 1994, illustrate how outcome data can be used to guide and test changes that will effect improvements over current practices. Example 1: Problem identification is one of the most obvious and immediate applications of outcome data relative to a quality improvement process. Data were presented at a meeting of the hospital medical staff; the data showed that one clinician had significantly poorer outcomes in treating bipolar patients. A review of the medical records for bipolar patients treated by this clinician indicated that this clinician was changing medications too rapidly, a problem that was quickly and easily corrected-with improved outcomes. Example 6: Data revealed that patients who were treated in accordance with the critical pathway showed a greater degree of improvement, even though these patients entered treatment with a 10% greater level of symptom intensity. SUMMARY AND CONCLUSIONS: Each example provides a sample of variability in outcomes and therefore an opportunity to study the reasons for the variability and institute changes

387.    Lerner, R. D. (1997). Psychiatry pathway: physicians make the process work and find benefits for themselves. Wisconsin Medical Journal, 96(10), 52-6.

388.    Knight, L., Livingston, N. A., Gawlinski, A., & DeLurgio, D. B. (1997). Caring for patients with third-generation implantable cardioverter defibrillators: from decision to implant to patient's return home. [Review] [46 refs]. Critical Care Nurse, 17(5), 46-51, 54-58, 60-61 passim; quiz 64-65.

389.    Kernodle, S. J. (1997). Improving health care with clinical practice guidelines and critical pathways: implications for pharmacists in ambulatory practice. [Review] [25 refs]. Pharmacy Practice Management Quarterly, 17(3), 76-89.

390.    Holecek, R. A., & Sellards, S. M. (1997). Use of a detailed clinical pathway for bone marrow transplant patients. [Review] [3 refs]. Journal of Pediatric Oncology Nursing, 14(4), 252-7.

391.    Helvig, E. I., Upright, J., & Bartleson, B. J. (1997). The development of outcome statements for burn care. Seminars in Perioperative Nursing, 6(4), 197-200.
Abstract: This article chronicles the development of an American Burn Association consensus document reflecting optimal goals for the delivery of burn care for use in clinical pathways and other quality improvement efforts. Outcome statements can measure progress toward meeting patient goals and can identify barriers in delivering optimal patient care

392.    Fidler, P. A., & Hibbs, C. J. (1997). Bone marrow transplant today--home tomorrow: ambulatory care issues in pediatric marrow transplantation. [Review] [15 refs]. Journal of Pediatric Oncology Nursing, 14(4), 228-38.
Abstract: Pediatric marrow transplantation is now an accepted and increasingly successful intensive therapy for a wide range of disorders in children. Supportive therapies that were once thought to be possible only in the acute care setting can now be safely managed in the outpatient arena. This shift is influenced by scientific and patient care advances and by managed care and cost containment trends. The purpose of this article is to examine the interrelated aspects of change in health care delivery and their impact on pediatric bone marrow transplant recipients and families. Nurses working in all aspects of pediatric marrow transplantation have an opportunity and responsibility to impact quality patient care in the outpatient setting. [References: 15]

393.    Droste, T. M. (1997). One system relies on partnering as a strategy to build a state network. Medical Network Strategy Report, 6(10), 1-3.

394.    Clayton, H. A., Boudreau, L., Rodman, R., Bak, S., Embry, K., & Fortier, J. (1997). Development of an ostomy competency. [Review] [3 refs]. MEDSURG Nursing, 6(5), 256-67; quiz 268-9.
Abstract: Staff educators and staff nurses developed an ostomy competency, with the guidance and expertise of the advanced practitioner and enterostomal nurse at a large teaching hospital. The competency improved the quality of care for surgical ostomy patients. Care was standardized and staff nurses' clinical knowledge was enhanced. Following the sessions, staff nurses verbalized increased confidence in working with patients with ostomies and demonstrated increased autonomy and problem-solving abilities. No variances in educational aspects of care were noted on clinical pathways. [References: 3]

395.    Breiterman-White, R., & Becker, B. N. (1997). The institution of care pathways in nephrology patient care: a response to the changing health care climate... percutaneous renal biopsy and vascular access surgery. Advances in Renal Replacement Therapy, 4(4), 340-9.
Abstract: The development of managed health care in the United States has provided an impetus for new strategies that promote efficiency, streamline healthcare delivery, and maintain quality care. The increasing number of end-stage renal disease patients, their complexity of care, and a looming manpower shortage in nephrology strain the present system trying to meet these demands. One mode of healthcare delivery that may address specific needs in the nephrology population is case management. This approach to medical care uses a care pathway that serves as a multidisciplinary blueprint for patient care. Such pathways eliminate duplicated services and maximize efficiency by keeping the healthcare team focused. In response to market forces in our community, we implemented care pathways for percutaneous renal biopsy and vascular access surgery. Costs per procedure and hospital length of stay were reduced. Patient outcomes and procedure success rates were unchanged from pre-pathway years. Moreover, patients preferred the care pathway care for their problems. Case management and care pathways are tools that are effective in their scope for helping deliver better care for nephrology patients. While they should not be considered a panacea for the problems facing renal care providers, these tools should be considered as part of nephrology healthcare delivery in the future.  (19 ref)

396.    Becker, B. N., Breiterman-White, R., Nylander, W., Van Buren, D., Fotiadis, C., Richie, R. E., & Schulman, G. (1997). Care pathway reduces hospitalizations and cost for hemodialysis vascular access surgery. American Journal of Kidney Diseases, 30(4), 525-31.
Abstract: Hemodialysis vascular access-related hospitalizations account for more than 20% of United States end-stage renal disease (ESRD) hospitalizations, with an annual cost approximating $675 million. Limiting access-related costs while delivering similar degrees of quality care thus would enhance alternative utilization of ESRD funding. We implemented a vascular access care pathway emphasizing coordinated patient evaluation and outpatient surgery to determine whether such an intervention affected outcomes associated with vascular access surgery. Data examining hospitalization and vascular access surgery charges, complications, and patient satisfaction (determined by questionnaire) were analyzed, comparing patients who underwent vascular access surgery in 1994 and 1995 as inpatients (non-care pathway patients) and patients who underwent vascular access surgery via the care pathway in 1995. Inpatient days declined in 1995 (1994: 582 days; 1995: 85 days; P < 0.03) and the average charges per patient for the care pathway cohort were significantly less than charges per patient in 1994 and charges for non-care pathway patients in 1995 (1994 patients: $10,524 +/- $5,209; 1995 non-care pathway patients: $11,196 +/- $5,806; 1995 care pathway patients: $4,686 +/- $2,912/patient; P < 0.02). Incidence rates for major (life-threatening) complications were not significantly different between 1994 patients and care pathway patients in 1995. However, the 1995 non-care pathway patients had a higher incidence of major complications (15.4%). Forty-seven repeat access procedures were performed in 29 patients in 1994 versus 35 repeat access procedures in 22 care pathway patients in 1995, and 12 repeat access procedures were performed in eight non-care pathway patients in 1995. Finally, a majority of the patients entered into the care pathway who responded to a survey stated that they were satisfied with access surgery via the care pathway. These data suggest that a vascular access care pathway can reduce hospital days and costs while achieving acceptable outcomes for access surgery

397.    Archer, S. B., Burnett, R. J., Flesch, L. V., Hobler, S. C., Bower, R. H., Nussbaum, M. S., & Fischer, J. E. (1997). Implementation of a clinical pathway decreases length of stay and hospital charges for patients undergoing total colectomy and ileal pouch/anal anastomosis. Surgery, 122(4), 699-703; discussion 703-5.
Abstract: BACKGROUND: Clinical pathways are increasingly being used by hospitals to improve efficiency in the care of certain patient populations; however, little prospective data are available to support their use. This study examined whether using a clinical pathway for patients undergoing ileal pouch/anal anastomosis, a complex procedure in which we had extensive practical experience, affected hospital charges or length of stay (LOS). METHODS: A clinical pathway was developed to serve patients undergoing elective total colectomy and ileal pouch/anal anastomosis. All operations were performed by two attending physicians (J.E.F., M.S.N.). Before implementation, 10 pilot patients were prospectively monitored to ensure that hospital charges were accurately generated. In addition, charge audits were performed by an outside agency to verify the accuracy of the hospital bills. The pathway was then implemented, and 14 patients were prospectively analyzed. RESULTS: In all patients the principal diagnosis was ulcerative colitis, with the exception of three patients with familial polyposis. Mean external audit charges were within 2% of the hospital bills; therefore the hospital bills were used in all calculations. The mean LOS decreased from 10.3 days to 7.5 days (p = 0.046) for patients on the pathway versus pilot patients. Mean hospital charges also decreased significantly, from $21,650 to $17,958 per patient (p = 0.005). CONCLUSIONS: Implementation of a clinical pathway, even for an operation in which the surgeon has much experience, is an effective method for reducing LOS and charges for patients. This is likely the result of interdisciplinary cooperation, elimination of unnecessary interventions, and streamlined involvement of ancillary services. These results support the development of clinical pathways for procedures that involve routine preoperative and postoperative care. In addition, the benefits of clinical pathways should increase proportionally with increasing case volume for a particular procedure

398.    Walsh, M. (1997). Will critical pathways replace the nursing process?. [Review] [16 refs]. Nursing Standard, 11(52), 39-42.
Abstract: Individualised care is the essence of nursing and regard for the individual is the battle against the impersonal institution. Unfortunately, attempts to manage the process of individualised care have often ended in failure (Ford and Walsh 1994). Some observers maintain that the rigid behaviour which characterises the nursing process contradicts the intuitive nature and individualistic approaches which are fundamental to nursing practice (Benner 1984). This article reviews the concept of critical pathways, a new approach to managing patient care. [References: 16]

399.    Ulmer, C., Lewis-Idema, D., Falik, M., Raggio, T. P., Stoessel, P., Coughlin, T., Butterworth, D., & Tillman, J. (1997). Categorical funding to seamless systems of care: the challenge for community-based primary care providers. Journal of Case Management, 6(3), 96-103.
Abstract: Integrating categorical funding to design "seamless systems of care" for individual patients is a challenge faced by many local community-based providers. Providers may choose to develop separate site-specific categorical programs for patients with human immunodeficiency virus (HIV) [e.g., specialized treatment site or a homeless clinic] or integrate these programs with their general primary care population. Regardless of program location, providers have developed patterns for finding the most appropriate medical home for a patient with multiple categorical risks. Medical records reviews and patient interviews indicate the importance of case managers in service coordination, although clinical issues appear more readily coordinated than situational ones. Provider dependence solely on case managers for service coordination, across sites and programs may become problematic in the era of managed care without a supportive information system that tracks client use and a records system that integrates clinical and social service notes. Local providers have encountered difficulties in exchanging essential medical information, even within a single agency, under state statutes regarding confidentiality of HIV test results

400.    Rafoth, R. J. (1997). Commentary: extended care paths and the continuum of care. American Journal of Medical Quality, 12(3), 157-9.

401.    Ozatalay, S., Proenca, E. J., & Rosko, M. D. (1997). Adoption of a time-based competition paradigm into the health care industry. Journal of Health & Human Services Administration, 20(2), 159-81.
Abstract: Market and regulatory pressures are requiring health care organizations to find new ways to compete. This article introduces the concept of time-based competition, a strategy adopted by firms in the manufacturing sector to strengthen their competitive positions, as a new strategy for health care organizations. The Just-in-Time technique and set-up time reduction activities are used to demonstrate the adoption of this paradigm by health care organizations. A case study comparing the movement of elderly patient through the health care delivery system under traditional and time-based competition practices is used to illustrate gains from adopting the new paradigm.  (Abstract by: Author)

402.    Staggers, N. (1997). Notes from a clinical information system program manager. A solid vision makes all the difference.  Computers in Nursing, 15(5), 232-3, 235.
Abstract: Today's CIS manager will create a vision that connects computerization in ambulatory, home and community-based care with increased responsibility for patients to assume self-care. Patients will be faced with a glut of information and they will need nursing help in determining the validity of information. The new vision in this environment will focus on integration, interoperability, and a new definition for patient-centered information. Creating a well-articulated vision is the first skill in the repertoire of a CIS manager's tool set. A vision provides the firm structure upon which the entire project can be built, and provides for links to life-cycle planning. This first step in project planning begins to bring order to the chaos of dynamic demands in clinical computing

403.    Ross, G., Johnson, D., Kobernick, M., & Pokriefka, R. (1997). Evaluation of a critical pathway for pneumonia. Journal for Healthcare Quality, 19(5), 22-9-36.
Abstract: Pneumonia is the third most frequent admission diagnosis at Macomb Hospital Center. The average length of stay for this diagnosis (DRGs 89 and 90) was 9.07 days. After the initiation of a critical pathway that begins in the emergency department, the average length of stay decreased to 7.11 days. Quality of care also improved in two areas: the time elapsed before delivery of antibiotics and availability of X-ray reports. This article reviews the implementation and results of the critical pathway for pneumonia.  (Abstract by: Author)

404.    Ott, R. A., Gutfinger, D. E., Miller, M., Alimadadian, H., Codini, M., Selvan, A., Moscoso, R., & Tanner, T. (1997). Rapid recovery of octogenarians following coronary artery bypass grafting. Journal of Cardiac Surgery, 12(5), 309-13.
Abstract: BACKGROUND: Rapid recovery protocols for coronary artery bypass grafting (CABG) have resulted in major decreases in postoperative hospital length of stay (LOS) when applied to younger patients undergoing elective procedures. However, the effectiveness of rapid recovery protocols when applied to octogenarians has not been thoroughly studied. METHODS: Thirty-seven consecutive octogenarians underwent isolated CABG utilizing cardiopulmonary bypass (CPB). A protocol emphasizing preoperative placement of the intra-aortic balloon pump, reduced CPB time, early extubation, perioperative steroids, thyroid hormone, and aggressive postoperative diuresis was used. RESULTS: The 30-day operative mortality for the entire series was 5.4%. Twenty-five patients (71%, group I) were discharged in < 10 days postoperatively (average LOS of 6.3 +/- 1.6 days), while ten patients (29%, group II) were discharged at 10 or more days postoperatively (average LOS of 20.3 +/- 8.0, p < 0.001). Patients in group II were found to have a higher incidence of obesity (50% vs 4%, p < 0.01), symptomatic peripheral vascular disease (60% vs 8%, p < 0.01), and preoperative ambulatory difficulties (50% vs 0%, p < 0.01). The incidence of complications was 31% for the entire series, with no differences between the groups. CONCLUSION: Octogenarians performed well under a rapid recovery protocol, with 71% being discharged in < 10 days postoperatively, while patients with obesity, symptomatic peripheral vascular disease, and ambulatory difficulties rehabilitated more slowly

405.    Maxey, C. (1997). A case map reduces time to administration of thrombolytic therapy in patients experiencing an acute myocardial infarction. Nursing Case Management, 2(5), 229-37.
Abstract: As one of the first hospitals in northwest Arkansas to begin administering thrombolytic therapy to patients with heart attack, or acute myocardial infarction (AMI), Crawford Memorial Hospital (CMH) first administered streptokinase to a patient experiencing an AMI on April 26, 1984. A national standard in lytic therapy was set in 1992 by the National Heart Attack Alert Program Coordinating Committee. The committee set a benchmark of having every appropriate AMI patient receive thrombolytic therapy within 30 minutes of hospital arrival. To monitor quality in lytic therapy administration, CMH began to participate in the National Registry for Myocardial Infarction (NRMI), in January 1995. The first quarter of data revealed a median door-to-drug time (time from arrival at hospital to administration of drug) of 67 minutes. As a quality improvement project, a research experiment was conducted to assess the effect of a case map, also referred to as a clinical pathway, on time to administration of thrombolytic therapy. A case map is a written management plan that provides the ideal sequence and timing of health care staff actions to achieve optimal patient outcomes with minimal variation in care. The researcher developed a case map designed to increase efficiency in delivery of thrombolytic agents. The research was conducted throughout an 18-month period from July 1995 until December 1996. Median time to administration of thrombolytic therapy was reduced from 64 minutes to 25 minutes as a result of case map use (p = 0.028). In this article, research findings are presented regarding the use of case maps in thrombolytic therapy, as well as implications for practice

406.    Johnson, L. G., & McMahan, M. J. (1997). Postoperative factors contributing to prolonged length of stay in cardiac surgery patients. Dimensions of Critical Care Nursing, 16(5), 243-50.
Abstract: In order to provide high quality, cost effective care, nurses need to identify and address factors that prolong the length of stay in various patient populations. The authors identify the postoperative factors contributing to prolonged length of stay in a cardiac surgery patient population and recommend collaborative management strategies to address these factors

407.    Goodman, D. (1997). Application of the critical pathway and integrated case teaching method to nursing orientation. Journal of Continuing Education in Nursing, 28(5), 205-10.
Abstract: BACKGROUND: Nursing staff development programs must be responsive to current changes in healthcare. New nursing staff must be prepared to manage continuous change and to function competently in clinical practice. METHOD: The orientation pathway, based on a case management model, is used as a structure for the orientation phase of staff development. The integrated case is incorporated as a teaching strategy in orientation. The integrated case method is based on discussion and analysis of patient situations with emphasis on role modeling and integration of theory and skill. RESULTS: The orientation pathway and integrated case teaching method provide a useful framework for orientation of new staff. Educators, preceptors and orientees find the structure provided by the orientation pathway very useful. CONCLUSION: Orientation that is developed, implemented and evaluated based on a case management model with the use of an orientation pathway and incorporation of an integrated case teaching method provides a standardized structure for orientation of new staff. This approach is designed for the adult learner, promotes conceptual reasoning, and encourages the social and contextual basis for continued learning

408.    Blumenfield, S. (1997). Ensuring social work competency with take-charge strategies. Continuum (Chicago), 17 (5), 9-14.

409.    Barish, R. A., Doherty, R. J., & Browne, B. J. (1997). Reengineering the emergency evaluation of chest pain. Journal for Healthcare Quality, 19(5), 6-12; quiz 60.
Abstract: This article presents strategies for enhancing the emergency department care delivered to patients with chest pain and suspected acute myocardial infarction. It also describes the planning and implementation of an emergency department reengineering project at a university medical center. The establishment of chest pain evaluation centers within emergency departments has been associated with improved clinical outcomes and cost control. Creating such a center requires careful revamping of diagnostic and treatment algorithms, a process that must be based on information from all departments affected by the changes.  (Abstract by: Author)

410.    Wang, A., Hall, S., Gilbey, H., & Ackland, T. (1997). Patient variability and the design of clinical pathways after primary total hip replacement surgery. Journal of Quality in Clinical Practice, 17(3), 123-9.
Abstract: Objective data are necessary for the design of clinical pathways of total hip replacement (THR) surgery. The functional recovery and timing for hospital discharge was studied in a consecutive series of 65 patients undergoing primary THR. The Modified Barthel Index (MBI) was serially measured after surgery to assess the recovery of functional independence. A MBI score of 90 out of a maximum of 100 is required before patients are fit for hospital discharge. The length of hospital stay varied from 5 days to 39 days. Fifty-eight percent of patients were fit for discharge by day 8, and 42% required 10 days or longer (mean = 14.2 days) in hospital. Patients in these two groups differed significantly with respect to age, the number of associated comorbidities, preoperative and early MBI scores, and muscle strength parameters. These data suggest that there is wide variability in patients presenting for primary THR. One single clinical pathway may not accommodate this patient variability, whereas two clinical pathways (one with a day 8 and another with an extended [day 10 +] time frame) may be more appropriate

411.    Spitzer, R. (1997). Understanding managed care: past, present, and future. Seminars for Nurse Managers, 5(3), 119-23.

412.    Simon, N. V., Heaps, K. P., & Chodroff, C. H. (1997). Improving the processes of care and outcomes in obstetrics/gynecology. Joint Commission Journal on Quality Improvement, 23(9), 485-97.
Abstract: BACKGROUND: The obstetrics/gynecology department of York Hospital (York Health System, York, Pennsylvania) initiated a program to improve the processes of care and control costs for common women's and newborns' health care services. Twelve clinical policies were established between June 1993 and February 1995. CONDUCTING THE QUALITY IMPROVEMENT (QI) PROJECTS: Using the plan-do-check-act (PDCA) improvement cycle method, the QI group established clinical pathways for high-volume conditions or procedures known to have low rates of complications and clinical guidelines for those conditions or procedures not requiring coordinated efforts of a group of health care professionals. EXAMPLE--PYELONEPHRITIS IN PREGNANCY: The literature had indicated that the prevalence of pyelonephritis can be decreased by identifying and treating asymptomatic bacteriuria early in prenatal care. After the validity of the clinical policy was demonstrated in the resident service, the policy was extended to all private obstetric practices. Dissemination of the finding that most of the admissions for pyelonephritis were for referred patients (for whom we had no control over prenatal care) or for patients referred by private physicians who were not yet following the guidelines quickly led to complete compliance by our obstetricians and other health care providers referring patients to the York Health System. RESULTS: The 12 clinical policies resulted in the elimination of 113 admissions and 5,595 inpatient days and in the reduction of the cost of patient care by $1,306,214 for the years 1994-1995 and 1995-1996 combined, without apparent adverse effects on patient health. CONCLUSION: A voluntary clinical policies program can change the culture of a department and lead to cost-effectiveness and better quality of patient care

413.    Odom, J. (1997). Conscious sedation in the ambulatory setting. [Review] [21 refs]. Critical Care Nursing Clinics of North America, 9(3), 361-70.
Abstract: Conscious sedation has become an important component of practice for many ambulatory procedures. Important factors to maintain the safety of this technique are proper patient selection, slow titration of the medication, continuous patient monitoring, proper education of the individuals administering the medication and monitoring the patient, and appropriate policies and guidelines in place in the ambulatory setting. When patient safety is the number one priority, conscious sedation can be a very effective, practical, and safe technique used in the ambulatory setting. [References: 21]

414.    Mathias, J. M. (1997). Clinical pathways. Case managers help map paths through OR. Or-Manager, 13(9), 31, 33-34, 36.

415.    Mathias, J. M. (1997). Case managers help map paths through OR. Or-Manager, 13(9), 31-6.

416.    Ireton-Jones, C., Orr, M., & Hennessy, K. (1997). Clinical pathways in home nutrition support. [Review] [13 refs]. Journal of the American Dietetic Association, 97(9), 1003-7.
Abstract: In home-care settings, physicians with various medical specialties may order home enteral and/or parenteral nutrition support. Clinical pathways may be used to provide a clear, concise, standardized method for ordering and monitoring home nutrition support. The clinical pathways should be appropriate for 80% of the patients placed on the pathways, allowing for a 20% variance, or deviation, from the pathway. In one home-care facility, disease-specific clinical pathways have been used for longer than 1 year for patients with a variety of diseases requiring home nutrition support. To determine the usefulness of the home nutrition support clinical pathways, data obtained from 20 patients were analyzed. Patients were followed up while being treated using home nutrition support clinical pathways designed for oncology (9 patients), human immunodeficiency virus/acquired immunodeficiency syndrome (2 patients), short bowel syndrome (6 patients), and hyperemesis (3 patients) for 191 weeks. Overall, an average variance (deviation from the pathway) of 22% (the number of variances divided by the total weeks of therapy) was observed. The use of the pathways to provide enteral or parenteral nutrition facilitated more cost-effective care by following pathway guidelines for obtaining laboratory values and patient visits. Communication between the home-care staff and the physician was also improved. Clinical pathways can enable standardization of care for patients receiving nutrition support at home. [References: 13]

417.    Hoyt, J. W. (1997). Debunking myths of chronic obstructive lung disease [editorial; comment]. Critical Care Medicine, 25(9), 1450-1.
Notes: Comments: Comment on: Crit Care Med 1997 Sep;25(9):1522-6

418.    Flickinger, J. E., Trusler, L., & Brock, J. W. 3rd. (1997). Clinical care pathway for the management of ureteroneocystostomy in the pediatric urology population. Journal of Urology, 158(3 Pt 2), 1221-5.
Abstract: PURPOSE: The management of vesicoureteral reflux continues to evolve. Endoscopic and laparoscopic techniques have been reported as alternatives to standard surgical techniques. However, the newer modalities have no long-term track record and there is some question as to efficacy. We sought to establish a clinical care pathway for managing ureteroneocystostomy in children. MATERIALS AND METHODS: In the last 4 years we have developed a management technique based on a clinical collaborative care pathway with the help of surgeon, house staff, clinical nurse specialist and support personnel, that is floor, operating room and post-anesthesia nurses. The pathway includes extensive preoperative parent and child education, standard intraoperative management and postoperative care without catheter drainage. It is based on a postoperative hospital stay of 2 days without a ureteral or urethral catheter. We report on the care of 110 consecutive patients (190 ureters) who underwent simple or common sheath ureteroneocystostomy from April 1992 to July 1996. RESULTS: No patient required the use of a urethral catheter or ureteral stent. Average length of hospital stay was 2.8 days and there were no immediate postoperative complications. At an average followup of 26 months (range 5 to 53) an overall success rate of 97% per patient and 98% per ureter was achieved. Analysis of the costs of simple and common sheath ureteroneocystostomy in the clinical care pathway revealed a 4% increase over those in an ideal case with no deviations from the pathway. Costs and length of hospital stay were then compared to those for institutions of the university hospital consortium and they were found to be 39 and 45% less, respectively. Outcome based analysis by telephone interview revealed 100% patient or parent satisfaction. CONCLUSIONS: We believe that the management of vesicoureteral reflux using a coordinated clinical care pathway significantly improves length of hospitalization and inpatient costs with a high satisfaction score from parents and patients. This health care delivery style provides a standard to which other vesicoureteral reflux procedures must be compared

419.    Davis, A., Griffin, D., Kahwaty, B., Lurie, N., & McNeill, D. (1997). Roundtable. Managed care: what issues do clinicians face in an evolving system? Jaapa/Journal of the American Academy of Physician Assistants, 10(9), 18-20, 29-30, 33-36 passim.

420.    Clarkson, B. D., Strife, A., Wisniewski, D., Lambek, C., & Carpino, N. (1997). New understanding of the pathogenesis of CML: a prototype of early neoplasia [see comments]. [Review] [179 refs]. Leukemia, 11(9), 1404-28.
Notes: Comment in: Leukemia 1998 Feb;12(2):136-8, Comment in: Leukemia 1998 Mar;12(3):444-5, Comment in: Leukemia 1998 Mar;12(3):446-7
Abstract: The 9;22 chromosomal translocation characteristic of CML results in a fused bcr/abl gene and an abnormal fusion protein, p210bcr/abl. Relative to normal c-abl, p210bc1/abl has elevated tyrosine kinase activity that is essential for its transforming activity. We recently reported a prominent 62 kDa GAP-associated P-tyr protein and five additional consistent but less prominent P-tyr proteins as well as five more minor P-tyr proteins that are constitutively tyrosine phosphorylated in primary primitive lineage negative (lin-) chronic phase CML blasts but not in comparable primary lin- normal blasts. The GAP-associated p62 protein has now been purified, sequenced and its gene has been cloned; it is a previously unidentified protein and is currently being characterized. In analyzing P-tyr proteins in primary lin- normal blasts in response to various hematopoietic cytokines, we found a striking similarity in the tyrosine phosphorylation of four major and three minor proteins after stimulation with c-kit ligand (KL) and the P-tyr proteins that are constitutively phosphorylated in primary primitive lin- chronic phase CML blasts. Other cytokines tested (ie GM-CSF, G-CSF, IL-3, FLT3 ligand, TPO, EPO) were much less active or stimulated phosphorylation of other proteins. KL/c-kit and bcr/abl have some similar activities including enhancing survival and expansion of hematopoietic progenitor cells, probably acting primarily on early progenitors at the time of lineage commitment rather than on self-renewing stem cells. Activation of growth factor receptors promote a cascade of protein phosphorylations that can ultimately result in a wide range of cellular responses. Sustained activation of discrete signaling pathways in some types of cells results in differentiation, whereas transient activation instead causes a proliferative response; in other cell types, the converse is true. It may be postulated that stem cells and primitive progenitors are at a particularly susceptible stage of development that renders them especially responsive to sustained bcr/abl-induced phorphorylation of a number of signaling proteins that are components of critical regulatory pathways, including c-kit. The affected pathways control and coordinate multiple diverse cell processes including proliferation, differentiation, maturation and apoptosis, processes that are normally tightly regulated and integrated. Perturbation of these key pathways in primitive progenitors would be expected to seriously disrupt orderly hematopoiesis and could also explain the multiple subtle pleiotropic biological abnormalities characteristically observed in later maturing CML compartments that we have collectively designated 'discordant maturation'. The true situation is undoubtedly very complex and involves interaction of multiple cytokines and signaling pathways that we are now trying to define. Constitutive downstream activation of critical pathways in susceptible early progenitors that normally require KL or other factors for activation could explain most if not all features of the disease. [References: 179]

421.    Bueno, M. M. (1997). Pathways and protocols alone aren't enough. Hospital Case Management, 5(9), 161-4.

422.    Bogle, M. L. (1997). Commentary. Challenges of pediatric nutrition therapy: do we cope with science or fiction? Topics in Clinical Nutrition, 12(4), 1-5.
Abstract: Pediatric nutrition therapy has traditionally been handed down from generation to generation, physician to physician, and dietitian to dietitian. The opportunity for science and research-based protocols and practice guidelines is at hand. Dietitians must assume leadership for clinical research, practice guidelines, and critical pathways in pediatric nutrition, collaborating with other disciplines. Collaboration with other dietitians and health professionals is critical to collect data and document successes and failures.  (13 ref)

423.    Bernstein, A. L. (1997). The diabetic foot. Critical pathways. Podiatry Management, 16(7), 25-26, 28.
Abstract: Developing guidelines for the evaluation and treatment of the pedal manifestations of diabetes mellitus

424.    Back, M. R., Harward, T. R., Huber, T. S., Carlton, L. M., Flynn, T. C., & Seeger, J. M. (1997). Improving the cost-effectiveness of carotid endarterectomy. Journal of Vascular Surgery, 26 (3), 456-62; discussion 463-4.
Abstract: PURPOSE: Carotid endarterectomy (CEA) has been shown to significantly reduce the risk of stroke caused by carotid artery stenosis. Limiting the costs of CEA without increasing the risks will improve the cost-effectiveness of this procedure. METHODS: Results were prospectively collected from 63 consecutive CEAs performed in 60 patients who were entered into a clinical pathway for CEA that included avoidance of cerebral arteriography, preferential use of regional anesthesia, selective use of the intensive care unit (ICU), and early hospital discharge. The mortality rate, complications, hospital costs, and net income in these patients were then compared with results from 45 CEAs performed in 42 consecutive patients immediately before beginning the CEA pathway. Age, comorbid risk factors, incidence of symptoms, and degree of carotid artery stenosis were similar in both patient groups. RESULTS: The rates of mortality and complications associated with CEA were low (mortality rate, 0%; stroke, 0.9%; transient ischemic attack, 2.8%) and did not vary between the two groups. Implementation of the CEA pathway resulted in significant (p < 0.001) reductions in the use of arteriography (74% to 13%), general anesthesia (100% to 24%), ICU use (98% to 30%), and mean hospital length of stay (5.8 days to 2.0 days). These changes resulted in a 41% reduction in mean total hospital cost ($9652 to $5699) and a 124% increase in mean net hospital income ($1804 to $4039) per CEA (p < 0.01). For the 39 patients (62%) who achieved all elements of the CEA pathway, the mean hospital length of stay was 1.3 days, the mean hospital cost was $4175, and the mean hospital income was $4327. CONCLUSIONS: Costs associated with CEA can be reduced substantially without increased risk. This makes CEA an extremely cost-effective treatment of carotid disease against which new therapeutic approaches must be measured

425.    Whyte, I. M., Dawson, A. H., Buckley, N. A., Carter, G. L., & Levey, C. M. (1997). Health care. A model for the management of self-poisoning. Medical Journal of Australia, 167(3), 142-6.
Abstract: OBJECTIVE: To describe the development and activity of a multidisciplinary service to manage self-poisoning. DESIGN: Descriptive, comparative study with prospective data collection. SETTING: Regional toxicology treatment centre in the Hunter area of New South Wales (NSW) with primary and secondary referral service to 385,000 people and tertiary referral service to a further 100,000. PATIENTS: All patients (1987-1995) with poisoning or envenomation presenting to the Hunter Area Toxicology Service (HATS). MAIN OUTCOME MEASURES: Average length of stay for HATS compared with national and NSW hospitals; mortality data for HATS compared with NSW. RESULTS: Average length of stay for HATS was 0.53-1.22 days shorter than for all Australian hospitals, potentially saving 518 bed-days, valued at $468,000 per year. Average length of stay was 0.94-3.39 days shorter than for all NSW hospitals, saving 1470 bed-days at $1.4 million per year. Inpatient mortality (0.2%; 95% confidence interval, 0.0-1.1) was not significantly different from NSW (0.5%; 95% CI, 0.2-0.8). Standardised mortality ratios showed no greater all-cause suicide mortality. CONCLUSIONS: In our centralised model for managing self-poisoning, all toxicology patients in an area health service are diverted to one hospital, where all patients with deliberate self-poisoning are admitted under the one multidisciplinary team, and all receive psychiatric assessment. This model has substantially reduced bed stay, with considerable savings to the Hunter Area Health Service manifested as an increase in beds available for other purposes

426.    Cook, D. J., Greengold, N. L., Ellrodt, A. G., & Weingarten, S. R. (1997). The relation between systematic reviews and practice guidelines. Annals of Internal Medicine, 127(3), 210-6.

427.    Zideman, D. A. (1997). Paediatric and neonatal life support. [Review] [106 refs]. British Journal of Anaesthesia, 79(2), 178-87.

428.    Wright, C. D., Wain, J. C., Grillo, H. C., Moncure, A. C., Macaluso, S. M., & Mathisen, D. J. (1997). Pulmonary lobectomy patient care pathway: a model to control cost and maintain quality. Annals of Thoracic Surgery, 64(2), 299-302.
Abstract: BACKGROUND: Cost containment is a reality in thoracic surgery. Patient care pathways have proved effective in cardiac surgery to reduce length of stay and control costs. METHODS: A multidisciplinary team formulated a pulmonary lobectomy patient care pathway to standardize care, reduce length of stay and costs, and maintain quality. Variance codes were developed to collect data prospectively on reasons for prolonged stay. A patient satisfaction survey was instituted to learn patients' responses to their hospitalization. RESULTS: One hundred forty-seven patients underwent lobectomy in 1995 before institution of the pathway with a mean length of stay of 10.6 days and a mean cost of $16,063. The lobectomy pathway was instituted at the beginning of 1996. One hundred thirty patients underwent lobectomy in 1996 with a mean length of stay of 7.5 days (p = 0.03) and a mean cost of $14,792 (p = 0.47). Readmission and mortality rates were unchanged. Eighty-eight of 130 patients (68%) were able to be discharged by the target length of stay of 7 days in 1996 as opposed to 76 of 147 patients (52%) in 1995. The most common reason for delayed discharge was inadequate pain control. The majority of patients felt prepared for discharge by the seventh postoperative day (70 of 96 patients, 73%). CONCLUSIONS: The institution of a lobectomy patient care pathway appeared to reduce length of stay and costs. The pathway provided a framework to begin systematic quality control measures to enhance patient care

429.    Wallenius, C. (1997). Developing critical paths... [letter; comment]. Nursing Management, 28(8), 12, 14.
Notes: Comment on: Nurs Manage 1996 Feb;27(2):49-51

430.    Taylor, G., & Rawson, R. (1997). Providing high-quality care for children. Caring, 16(8), 50-1.
Abstract: Because home care traditionally has served older patients under Medicare, some providers tend to treat in-home pediatric patients like "little adults." To offer children and their families the specialty care that they require and deserve, one agency limits its services exclusively to pediatrics.  (Abstract by: Author)

431.    Short, M. S. (1997). Charting by exception on a clinical pathway. Nursing Management, 28(8), 45-6.
Abstract: A study at one medical center showed that nurses were spending 2.5 hours per shift documenting patient care. After charting by exception was integrated with a clinical pathway, charting time dropped to 0.82 hours per shift. Results of a pilot project on an orthopedic/neurologic patient care unit are discussed

432.    Shelton, D. M. (1997). Computerized deep vein thrombosis path allows patient management, not data management. Hospital Case Management, 5(8), 141-4.

433.    Shabot, M. M. (1997). The HP CareVue clinical information system. International Journal of Clinical Monitoring & Computing, 14(3), 177-84.
Abstract: The HP CareVue system is an object-oriented, client-server system optimized for critical care, inpatient and special care environments. It is a fully graphical system, highly visual in its mode of operation, which requires no commands to operate. Data review may be performed by clinical users without specific instructions. Several different kinds of interfaces are provided for the system. These allow it to be connected to most hospital data-producing systems, physiologic monitors and bedside devices, such as ventilators, urimeters and oximeters. Flowsheet charting, free text, structured notes, clinical pathways, configurable forms, medication administration records and many other types of displays and reports allow the system to function as a nearly complete Electronic Medical Record (EMR). The system is highly configurable by lead nurses, physicians or technicians without programming knowledge or experience. Configuration and linking of multiple CareVue systems is possible, including a complete testing environment for verification of charting changes before clinical activation. All CareVue data is exportable for purposes of electronic archiving, warehousing and real-time decision support

434.    Schroeder, P. (1997). PI3: performance improvement, ideas & innovations. Bringing clinical pathways to life. Journal of Nursing Care Quality, 11(6), 7-8.

435.   Regnier, S. J. (1997). Symposium explores information management in the OR. Bulletin of the American College of Surgeons, 82(8), 53-7.

436.    Nesbit, M. J., Hill, M., & Peterson, N. (1997). A comprehensive pediatric bereavement program: the patterns of your life. Critical Care Nursing Quarterly, 20(2), 48-62.
Abstract: The death of a child is one of the most painful experiences a parent can endure. Communicating and meeting the needs of parents during this time of crisis is a challenge for nurses. Pediatric intensive care unit and emergency department nurses who may feel overwhelmed and inadequate when working with grieving families, especially with a sudden and unexpected death, are assisted by "The Patterns of Your Life: A Comprehensive Pediatric Bereavement Program." The program is a blending of critical pathways (an element of managed care), educational resources, and family follow-up for 1 year. Preliminary evaluations indicate that the comprehensive bereavement program appears to have many benefits for families and health care staff alike

437.    Mathias, J. M. (1997). Clinical pathway leads to infection control changes. Or-Manager, 12(8), 23.

438.    Maklebust, J. (1997). Pressure ulcer assessment. [Review] [62 refs]. Clinics in Geriatric Medicine, 13(3), 455-81.
Abstract: Pressure ulcer assessment requires quantification of multiple parameters of the ulcer and periulcer tissue. Clinical assessment should include ulcer history (including etiology, duration, and prior treatment), anatomic location, stage, size (including length, width, and depth measured in centimeters), sinus tracts, undermining, tunneling, exudate or drainage, necrotic tissue (slough and eschar), presence or absence of granulation tissue, and epithelialization. In addition, the ulcer borders can provide clues to healing potential. Intact skin surrounding the ulcer should be assessed for redness, warmth, induration or hardness, swelling, and any obvious signs of clinical infection. Pressure ulcer associated pain should be assessed prior to examination of the ulcer. [References: 62]

439.    Kinney, C. F., & Gift, R. G. (1997). Building a framework for multiple improvement initiatives. Joint Commission Journal on Quality Improvement, 23(8), 407-23.
Abstract: BACKGROUND: As health care organizations struggle to compete and even survive in today's turbulent marketplace, they often juggle a variety of initiatives addressing cost reduction, quality improvement, critical pathways, accreditation, clinical guidelines, strategic planning, and organizational development-each with its own priorities, advocates, methods, and language. EXAMPLE: One large health care system that had adopted continuous quality improvement (CQI) as a major strategy then responded to significant cost pressures with additional initiatives in reengineering, cost reduction, and physician guidelines, with varying connections to the quality language, principles, and methods. The senior leadership committee for the quality initiative undertook the development of a framework to explain the connections among the diverse projects and approaches-a framework still in use after two years. SUMMARY AND CONCLUSION: In this period of enormous change, health care leaders must quickly and effectively mobilize all available resources to optimize organizational effectiveness. Too often, management's response patterns have overemphasized a "splitting" tactic, managing multiple distinct initiatives. The creation of integrated delivery systems, mergers, acquisitions, and alliance exacerbates this problem, as the number of initiatives multiplies in the new organizations. Development and application of an integrating management framework will accelerate the pace of organizational improvement by increasing shared understanding of the current desired states of the organization; linking strategic, cultural, and method needs and behaviors; aligning various management initiatives in relation to organizational goals and one another; increasing the fit of management methods with specific situations; and providing a unifying perspective and language for organizational members to act and learn collaboratively

440.    Dardik, A., Williams, G. M., Minken, S. L., & Perler, B. A. (1997). Impact of a critical pathway on the results of carotid endarterectomy in a tertiary care university hospital: effect of methods on outcome [see comments]. Journal of Vascular Surgery, 26(2), 186-92.
Notes: Comment in: J Vasc Surg 1998 Jan;27(1):190-1
Abstract: PURPOSE: A carotid endarterectomy critical pathway (CP) targeting a 3-day postoperative course was introduced in March 1994. This retrospective analysis assesses its impact on operative results, postoperative length of stay (POD), and cost of hospitalization (COH). METHODS: One hundred eighty-six patients who underwent 201 carotid endarterectomy procedures from Nov. 1992 to Feb. 1994 (Pre-CP; n = 67) and from Apr. 1994 to Jul. 1995 (Post-CP; n = 134) at Johns Hopkins Hospital, a tertiary care referral center, were evaluated. RESULTS: The Pre-CP and Post-CP groups had similar risk factors, postoperative morbidity rates, and mortality rates. Furthermore, they had similar mean POD (Pre-CP, 6.0 +/- 0.5 days; Post-CP, 5.7 +/- 0.6 days; p = 0.79) and COH. However, only 85 of the Post-CP (63%) patients were actually placed on the CP (CP-starters); the mean POD was 3.4 +/- 0.3 days among these CP-starters (p < 0.0001) and 2.8 +/- 0.1 days among the 74 Post-CP patients (55%) that remained on the pathway (CP-finishers; p < 0.0001). The mean COH was reduced from $12,881 (Pre-CP) to $9701 for the CP-starters (p = 0.01) and to $8572 for the CP-finishers (p = 0.0001). However, we found that only 47 of the Pre-CP patients (70%) would have been eligible for the CP, and the mean POD among those cases was 4.2 +/- 0.4 days, which was not different than the mean POD among the CP-starters (p = 0.17). The mean COH of the eligible Pre-CP cases, $9508, was not significantly different from the COH of the CP-starters (p = 0.97). CONCLUSIONS: This subset analysis emphasizes the importance of establishing an accurate "control" group when studying a CP, because using all of the Pre-CP cases as the "control" group in the original analysis, including patients who would not have been candidates for the CP, clearly overstated the beneficial impact of the CP

441.    Collier, P. E. (1997). Do clinical pathways for major vascular surgery improve outcomes and reduce cost? Journal of Vascular Surgery, 26(2), 179-85.
Abstract: PURPOSE: This study was performed to determine whether the implementation of clinical pathways for patients who undergo major vascular procedures in a community hospital would shorten the length of stay and reduce charges when compared with Medicare standards. METHODS: Length of stay, hospital costs, and morbidity, mortality, and readmission rates for the four most common vascular diagnosis-related group (DRG) categories at our institution were compared with Medicare standards. The four categories were DRG 005 (extracranial vascular procedures), DRG 110 (aortic and renal procedures), DRG 478 (leg bypass with comorbidity), and DRG 479 (leg bypass without comorbidity). Between May 1, 1994, and June 30, 1996, 112 patients underwent carotid endarterectomy, 42 patients underwent aortic or renal procedures, and 130 patients underwent lower extremity bypass procedures (68% with comorbidity). Only Medicare patients were included because exact cost/reimbursement data were available. No admissions were excluded. RESULTS: The average length of stay was 1.2 days for DRG 005, 6.9 days for DRG 110, and 3.2 and 2.1 days for DRGs 478 and 479, respectively. The average cost savings when compared with the Medicare reimbursement was $4338 for DRG 005, $7161 for DRG 110, $4108 for DRG 478, and $2313 for DRG 479. Readmission was necessary for 9% of peripheral bypass patients. Ten percent of patients in DRG 005 and 86% of patients in DRG 110 needed intensive care, whereas only 2% of patients who underwent complicated bypass procedures did. Ninety percent of carotid endarterectomy patients and 23% of leg bypass patients were discharged on the first postoperative day. There were two postoperative strokes (2%) after carotid surgery. Thirty-three percent of aortic/renal patients had complications that led to care outside the clinical pathway. Twenty-five percent of leg bypass patients required home care to treat open foot wounds. Total inpatient cost savings were $1,256,000 when compared with Medicare reimbursement. CONCLUSIONS: Clinical pathways significantly improve the length of stay and decrease inpatient charges for major vascular surgical procedures while maintaining high standards of care. Factors that favorably affected the length of stay and hospital charges were outpatient arteriography, same-day admission, early ambulation, physical therapy, home care, use of the intensive care unit on a selective basis, and early discharge. Factors that adversely affected these outcomes were emergency admission, inpatient arteriography, thrombolytic therapy, complications, and the need for dialysis or anticoagulation

442.    Collares-Pereira, M., Gomes, A. C., Prassad, M., Vaz, R. G., Ferrinho, P., Stanek, G., & Rosario, V. E. (1997). Preliminary survey of Leptospirosis and Lyme disease amongst febrile patients attending community hospital ambulatory care in Maputo, Mozambique. Central African Journal of Medicine, 43(8), 234-8.
Abstract: OBJECTIVES: To evaluate the importance of the spirochetes Leptospira interrogans s.l. and Borrelia burgdorferi s.l., as causes of human diseases (leptospirosis and Lyme borreliosis), in order to guide the development of laboratory services and patient management and to identify the appropriateness of future epidemiological studies. DESIGN: Cross sectional serological survey. SETTING: Maputo, the capital city of Mozambique. SUBJECTS: 160 adult patients (18 to 50 years of age) presenting, sequentially and for the first time, with a febrile illness at the outpatient's department of a community hospital. METHODS: All sera were examined for L. interrogans s.l. antibodies by the standard microtiter technique (MAT), using as live culture antigens a battery of serovars representing 20 pathogenic serogroups. The IgM and IgG antibody response to B. burgdorferi s.l. was determined in all sera with an indirect IgG ELISA. In order to study potential serological cross-reactivity in malaria positive sera, all samples were further examined for antibodies against Plasmodium falciparum by indirect immunofluorescence. This was complemented with a standardised clinical history and physical examination. MAIN OUTCOME MEASURES: Presence of antibodies to Leptospira interrogans s.l. and to Borrelia burgdorferi s.l.. RESULTS AND CONCLUSIONS: Although not conclusive, because of the inability to attempt rising serology and positive cultures, the results suggest that 10% of non-specific febrile illnesses could be attributed to leptospirosis. This study may thus form the background for a definitive Leptospira research in the same location. We confirm reports from other African countries that Lyme disease is an unlikely occurrence. We further suggest that some of the seropositivity observed for Lyme disease in Maputo could be attributed to serological cross reactivity with antibodies to P. falciparum malaria, leptospirosis or syphilis

443.    Brunelle, D., & Suarez, S. (1997). Interdisciplinary teams ensure guideline compliance. Hospital Case Management, 5(8), suppl 1-4.

444.    Bridgeman, T., Flores, M., Rosenbluth, J., & Pierog, J. (1997). One emergency department's experience: clinical algorithms and documentation. Emergency Medicine Specialists of Orange County. Journal of Emergency Nursing, 23(4), 316-25.

445.    Bayard, J. M., Calianno, C., & Mee, C. L. (1997). Care coordinator--blending roles to improve patient outcomes. Nursing Management, 28(8), 49-51; quiz 52.
Abstract: A care coordinator blends aspects of the case manager and clinical specialist roles with those of a unit-based staff developer. In this position, the nurse facilitates critical pathways; coordinates care with the patient, family, ancillary staff and community services; delivers unit-based staff-development programs; and acts as mentor, staff resource person and physician liaison. The development and utilization of this professional nursing role in a community hospital is outlined

446.    Baird, A. (1997). Clinical pathways: a road map to improving care. Point of View, 34(2), 10-12.

447.    Zagor, K. B. (1997). Capitation control with case management. Remington Report, 5(4), 43-47.
Abstract: The author examines how home care businesses can achieve success by implementing a capitated case management model for Medicare-, Medicaid-, and commercially-insured patient populations. Key to success is the quality of the case management directing the patient care, rather than strictly the quantity of care, the author emphasizes. The needed development of a regional case management center is discussed, along with the care planning strategies which the case managers need to define. The author recommends the follow strategies for case managers, such as use critical pathways to define an initial structure or frame of reference and also use creativity. In addition she suggests looking beyond the confines of HCFA coverage definitions to better reach care goals; to use time management for defining visits and days of care, thus controlling costs; ascertaining the patient's prior level of functioning to avoid erroneous expectations for improved outcomes; and defining comorbidities, to adjust expectations of caregivers' success. The author emphasized focusing on confining care goals to narrowly defined current episodes of care to establish reasonable expectations of patient health outcomes

448.    Strassner, L. (1997). Scanner technology to manage critical path variance analysis. [Review] [6 refs]. Nursing Case Management, 2(4), 141-7.

449.    Schaffer, C., & Behrendt, D. (1997). Disease state management across the continuum: bettering lives, providing value. Remington Report, 5(5), 20-23.
Abstract: The disease state management (DSM) approach to healthcare is described, in its spans across the continuum of care, from prevention and education to diagnosis and treatment to follow-up care and maintenance. An integrated approach to patient care is emphasized in DSM programs, and the authors identify planning strategies which use treatment protocols, or clinical pathways. Through use of clinical pathways, the need for interventions can be identified in a more timely manner. The authors focus on DSM programs' emphasis on patient education and empowerment, and describe some of the teaching components in which chronic disease patients can participate. They and their families learn, for example, proper techniques for self care and how to avoid acute episodes. The tasks of the DSM case manager are defined, and include program evaluation and outcome measurements

450.    Peters, B. (1997). Clinical pathways: a roadway for providers. Michigan Health & Hospitals, 33(4), 76-7.
Abstract: The steady growth of managed care, combined with advances in both medical and computer science, has begun to transform the way health care providers treat patients. The evolution and rapidly expanding use of clinical pathways has become an important component of the modern health care system.  (Abstract by: Author)

451.    Mayer, G. (1997). The impact of managed care on hospital nursing. [Review] [0 refs]. Best Practices & Benchmarking in Healthcare, 2(4), 162-7.
Abstract: There is a significant but different role for hospital staff nurses within a managed care environment. This article describes the role and reviews major areas where the staff nurse is critical in achieving positive patient outcomes that are cost-effective and efficient. [References: 0]

452.    Luther, T., & Crofts, L. (1997). Managed care: development of an integrated care pathway in neurosciences... including commentary by Wall M. Nt Research, 2(4), 283-91.
Abstract: The concept of managed care is emerging as a multidisciplinary approach to health care in the United Kingdom. It is implemented through an integrated care pathway (ICP) or care map which is created by the multidisciplinary team around a specific diagnostic group. The ICP consists of key interventions which can be evidence-based, incorporating clinical guidelines where appropriate. The aim of managed care is to improve quality of care while reducing length of stay, thus reducing costs. A pilot project was carried out in the neurosciences unit of a London teaching hospital over a six-month period. Lumbar disc surgery was chosen as the diagnostic group. Outcomes were better coordination of care and less variation in length of stay as well as improved communication and collaboration between the multi-professionals involved. Drawbacks were poor compliance by some clinicians and the time-consuming nature of creating the care map. Recommendations are that where ICPs are used this should be a single record replacing all other documentation.  (22 ref)

453.    Kazzaz, Y., Levey, S., McKnight, M., & Schnitzler, M. A. (1997). Opportunities for potential cost saving in the management of acute myocardial infarction. Best Practices & Benchmarking in Healthcare: a Practical Journal for