Why use clinical pathways rather than practice guidelines?

Clinical Pathways for Oncological Gastrectomy: Are They a Suitable Instrument for Process Standardization to Improve Process and Outcome Quality for Patients Undergoing Gastrectomy? A Retrospective Cohort Study

(1) Background: Oncological gastrectomy requires complex multidisciplinary management. Clinical pathways (CPs) can potentially facilitate this task, but evidence related to their use in managing oncological gastrectomy is limited. This study evaluated the effect of a CP for oncological gastrectomy on process and outcome quality. (2) Methods: Consecutive patients undergoing oncological gastrectomy before (n = 64) or after (n = 62) the introduction of a CP were evaluated. Assessed parameters included catheter and drain management, postoperative mobilization, resumption of diet and length of stay. Morbidity, mortality, reoperation and readmission rates were used as indicators of outcome quality. (3) Results: Enteral nutrition was initiated significantly earlier after CP implementation (5.0 vs. 7.0 days, p < 0.0001). Readmission was more frequent before CP implementation (7.8% vs. 0.0%, p = 0.05). Incentive spirometer usage increased following CP implementation (100% vs. 90.6%, p = 0.11). Mortality, morbidity and reoperation rates remained unchanged. (4) Conclusions: After implementation of an oncological gastrectomy CP, process quality improved, while indicators of outcome quality such as mortality and reoperation rates remained unchanged. CPs are a promising tool to standardize perioperative care for oncological gastrectomy.

Influence of Clinical pathways on treatment and outcome quality for patients undergoing pancreatoduodenectomy? A retrospective cohort study

BACKGROUND

Pancreatic surgery demands complex multidisciplinary management. Clinical pathways (CPs) are a tool to facilitate this task, but evidence for their utility in pancreatic surgery is scarce. This study evaluated the effect of CPs on quality of care for pancreatoduodenectomy.

METHODS

Data of all consecutive patients who underwent pancreatoduodenectomy before (n = 147) or after (n = 148) CP introduction were evaluated regarding catheter and drain management, postoperative mobilization, pancreatic enzyme substitution, resumption of diet and length of stay. Outcome quality was assessed using glycaemia management, morbidity, mortality, reoperation and readmission rates.

RESULTS

Catheters and abdominal drainages were removed significantly earlier in patients treated with CP (p < 0.0001). First intake of liquids, nutritional supplement and solids was significantly earlier in the CP group (p < 0.0001). Exocrine insufficiency was significantly less common after CP implementation (47.3% vs. 69.7%, p < 0.0001). The number of patients receiving intraoperative transfusion dropped significantly after CP implementation (p = 0.0005) and transfusion rate was more frequent in the pre-CP group (p = 0.05). The median number of days with maximum pain level >3 was significantly higher in the CP group (p < 0.0001). There was no significant difference in mortality, morbidity, reoperation and readmission rates.

CONCLUSIONS

Following implementation of a CP for pancreatoduodenectomy, several indicators of process and outcome quality improved, while others such as mortality and reoperation rates remained unchanged. CPs are a promising tool to improve quality of care in pancreatic surgery.

Clinical Pathways For Pancreatic Surgery: Are They A Suitable Instrument For Process Standardization To Improve Process And Outcome Quality Of Patients Undergoing Distal And Total Pancreatectomy? - A Retrospective Cohort Study

Purpose

Pancreatic surgery demands complex multidisciplinary management, which is often cumbersome to implement. Clinical pathways (CPs) are a tool to facilitate this task, but evidence for their utility in pancreatic surgery is scarce. This study evaluated if CPs are a suitable tool for process standardization in order to improve process and outcome quality in patients undergoing distal and total pancreatectomy.

Patients and methods

Data of consecutive patients who underwent distal or total pancreatectomy before (n=67) or after (n=61) CP introduction were evaluated regarding catheter management, postoperative mobilization, pancreatic enzyme substitution, resumption of diet and length of stay. Outcome quality was assessed using glycaemia management, morbidity, mortality, reoperation and readmission rates.

Results

The usage of incentive spirometers for pneumonia prophylaxis increased. The median number of days with hyperglycemia decreased significantly from 2.5 to 0. For distal pancreatectomy, the incidence of postoperative diabetes dropped from 27.9% to 7.1% (p=0.012). The incidence of postoperative exocrine pancreatic insufficiency decreased from 37.2% to 11.9% (p=0.007). There was no significant difference in mortality, morbidity, reoperation and readmission rates between groups.

Conclusion

Following implementation of a pancreatic surgery CP, several indicators of process and outcome quality improved, while others such as mortality and reoperation rates remained unchanged. CPs are a promising tool to improve quality of care in pancreatic surgery.

Clinical guidelines and patient related outcomes: summary of evidence and recommendations

Purpose

Good medical practice, evidence-based medicine (EBM) and clinical practice guidelines (CPG) have been recurring subjects in the scientific literature. EBM advocates argue that good medical practice should be guided by evidence-based CPG. On the other hand, critical authors of EBM methodology argue that various interests undermine the quality of evidence and reliability of CPG recommendations. The purpose of this paper is to evaluate patient related outcomes of CPG implementation, in light of EBM critics.

Design/methodology/approach

The authors opted for a rapid literature review.

Findings

There are few studies evaluating the effectiveness of CPG in patient-related outcomes. The systematic reviews found are not conclusive, although they suggest a positive impact of CPGs in relevant outcomes.

Research limitations/implications

This work was not a systematic review of literature, which is its main limitation. On the other hand, arguments from EBM and CPG critics were considered, and thus it can enlighten health institutions to recognize the caveats and to establish policies toward care improvement.

Originality/value

The paper is the first of its kind to discuss, based on the published literature, next steps toward better health practice, while acknowledging the caveats of this process.

Developing management pathways for hypertensive disorders of pregnancy (HDP) in Indonesian primary care: a study protocol

Background

National and international guidelines for the management of hypertensive disorders of pregnancy (HDP) are available in developing countries. However, more detailed clinical pathways for primary care settings are limited. This study focuses on Indonesia, where 72% of women who died from HDP and its complications had received less appropriate treatment according to international guidelines. There is an urgent need to develop primary care focused pathways that enable general practitioners (GPs), midwives and other relevant providers to manage HDP better.

Objectives

This paper describes a study protocol for the development of HDP management pathways for Indonesian primary care settings.

Methods

This study design is informed by Implementation Science theories and consists of three phases. The exploratory phase will involve conducting semi-structured interviews with key Indonesian primary care stakeholders to explore their experiences and views on HDP management. The development phase will apply evidence from the literature review and results of the exploratory phase to develop HDP management pathways contextualised to Indonesian primary care settings. Consensus will be sought from approximately 50 experts, consist of general practitioners (GPs), midwives, obstetricians, nurses and policy makers using Delphi technique survey. The evaluation phase will involve a pilot study to evaluate the pathways’ acceptability and feasibility in a sample of Indonesian primary care practices using mixed methods.

Discussion

The implementation science frameworks inform and guide the phases in this study. Qualitative interviews in the exploratory phase are conducive to eliciting opinions from key stakeholders. Using Delphi technique at the development phase is suitable to seek participants’ consensus on HDP management in primary care. Observations, focus group discussions, interviews as well as analysis of patients’ medical records at the evaluation phase are expected to provide a comprehensive investigation of the implementation of the pathways in practice settings.

Process Mining Methodology for Health Process Tracking Using Real-Time Indoor Location Systems

The definition of efficient and accurate health processes in hospitals is crucial for ensuring an adequate quality of service. Knowing and improving the behavior of the surgical processes in a hospital can improve the number of patients that can be operated on using the same resources. However, the measure of this process is usually made in an obtrusive way, forcing nurses to get information and time data, affecting the proper process and generating inaccurate data due to human errors during the stressful journey of health staff in the operating theater. The use of indoor location systems can take time information about the process in an unobtrusive way, freeing nurses, allowing them to engage in purely welfare work. However, it is necessary to present these data in a understandable way for health professionals, who cannot deal with large amounts of historical localization log data. The use of process mining techniques can deal with this problem, offering an easily understandable view of the process. In this paper, we present a tool and a process mining-based methodology that, using indoor location systems, enables health staff not only to represent the process, but to know precise information about the deployment of the process in an unobtrusive and transparent way. We have successfully tested this tool in a real surgical area with 3613 patients during February, March and April of 2015.

A collaborative approach to care for patients with periodontitis and diabetes

As periodontal disease and diabetes mellitus (DM) have bidirectional interactions, an effective approach to periodontal treatment for patients with diabetes in the clinical setting is essential. This paper reports an effort in collaborative care for patients with periodontitis and diabetes between dental and medical professionals, and provides a preliminary evaluation regarding the clinical outcomes. We have introduced a clinical pathway program at our institution applicable to patients with periodontitis and DM. Physicians and dentists utilize the clinical pathway to share medical and dental information in order to provide the optimal care for each patient. So far, this clinical pathway has been applied to the treatment of 50 patients. We analyzed clinical outcomes in 10 patients with the chief complaint of periodontal problems who had also been diagnosed with type 2 DM. After initial periodontal therapy and diabetes care, a significant improvement in the mean value of glycated hemoglobin and fasting plasma glucose was observed, accompanied by clinical resolution of periodontal parameters. Within the limitations of the present study, the results suggest that collaborative care between periodontists and physicians based on the clinical pathway is effective in glycemic control of patients with periodontitis and type 2 DM. This indicates the need for closer collaboration between medical and dental professionals in improving the management of these diseases.

Discovery of clinical pathway patterns from event logs using probabilistic topic models

Discovery of clinical pathway (CP) patterns has experienced increased attention over the years due to its importance for revealing the structure, semantics and dynamics of CPs, and to its usefulness for providing clinicians with explicit knowledge which can be directly used to guide treatment activities of individual patients. Generally, discovery of CP patterns is a challenging task as treatment behaviors in CPs often have a large variability depending on factors such as time, location and patient individual. Based on the assumption that CP patterns can be derived from clinical event logs which usually record various treatment activities in CP executions, this study proposes a novel approach to CP pattern discovery by modeling CPs using mixtures of an extension to the Latent Dirichlet Allocation family that jointly models various treatment activities and their occurring time stamps in CPs. Clinical case studies are performed to evaluate the proposed approach via real-world data sets recording typical treatment behaviors in patient careflow. The obtained results demonstrate the suitability of the proposed approach for CP pattern discovery, and indicate the promise in research efforts related to CP analysis and optimization.

Summarizing clinical pathways from event logs

OBJECTIVE

Clinical pathway analysis, as a pivotal issue in ensuring specialized, standardized, normalized and sophisticated therapy procedures, is receiving increasing attention in the field of medical informatics. Research in clinical pathway analysis has so far mostly focused on looking at aggregated data seen from an external perspective, and only provide very limited insight into the pathways. In some recent work, process mining techniques have been studied in discovering clinical pathway models from data. While it is interesting, discovered models may provide too much detail to give a comprehensive summary of the pathway. Moreover, the number of patterns discovered can be large. Alternatively, this article presents a new approach to build a concise and comprehensive summary that describes the entire structure of a clinical pathway, while revealing essential/critical medical behaviors in specific time intervals over the whole time period of the pathway.

METHODS

The presented approach summarizes a clinical pathway from the collected clinical event log, which regularly records all kinds of patient therapy and treatment activities in clinical workflow by various hospital information systems. The proposed approach formally defines the clinical pathway summarization problem as an optimization problem that can be solved in polynomial time by using a dynamic-programming algorithm. More specifically, given an input event log, the presented approach summarizes the pathway by segmenting the observed time period of the pathway into continuous and overlapping time intervals, and discovering frequent medical behavior patterns in each specific time interval from the log.

RESULTS

The proposed approach is evaluated via real-world data-sets, which are extracted from Zhejiang Huzhou Central hospital of China with regard to four specific diseases, i.e., bronchial lung cancer, colon cancer, gastric cancer, and cerebral infarction, in two years (2007.08-2009.09). Although the medical behaviors contained in these logs are very diverse and heterogeneous, experimental results indicates that the presented approach is feasible to construct condensed clinical pathway summaries in polynomial time from the collected logs, and have a linear scalability against the increasing size of the logs.

CONCLUSION

Experiments on real data-sets illustrate that the presented approach is efficient and discovers high-quality results: the observed time period of a clinical pathway is correctly segmented into a set of continuous and overlapping time intervals, in which essential/critical medical behaviors are well discovered from the event log to form the backbone of a clinical pathway. The experimental results indicate that the generated clinical pathway summary not only reveals the global structure of a pathway, but also provides a thorough understanding of the way in which actual medical behaviors are practiced in specific time intervals, which might be essential from the perspectives of clinical pathway analysis and improvement.

On mining clinical pathway patterns from medical behaviors

OBJECTIVE

Clinical pathway analysis, as a pivotal issue in ensuring specialized, standardized, normalized and sophisticated therapy procedures, is receiving increasing attention in the field of medical informatics. Clinical pathway pattern mining is one of the most important components of clinical pathway analysis and aims to discover which medical behaviors are essential/critical for clinical pathways, and also where temporal orders of these medical behaviors are quantified with numerical bounds. Even though existing clinical pathway pattern mining techniques can tell us which medical behaviors are frequently performed and in which order, they seldom precisely provide quantified temporal order information of critical medical behaviors in clinical pathways.

METHODS

This study adopts process mining to analyze clinical pathways. The key contribution of the paper is to develop a new process mining approach to find a set of clinical pathway patterns given a specific clinical workflow log and minimum support threshold. The proposed approach not only discovers which critical medical behaviors are performed and in which order, but also provides comprehensive knowledge about quantified temporal orders of medical behaviors in clinical pathways.

RESULTS

The proposed approach is evaluated via real-world data-sets, which are extracted from Zhejiang Huzhou Central hospital of China with regard to six specific diseases, i.e., bronchial lung cancer, gastric cancer, cerebral hemorrhage, breast cancer, infarction, and colon cancer, in two years (2007.08-2009.09). As compared to the general sequence pattern mining algorithm, the proposed approach consumes less processing time, generates quite a smaller number of clinical pathway patterns, and has a linear scalability in terms of execution time against the increasing size of data sets.

CONCLUSION

The experimental results indicate the applicability of the proposed approach, based on which it is possible to discover clinical pathway patterns that can cover most frequent medical behaviors that are most regularly encountered in clinical practice. Therefore, it holds significant promise in research efforts related to the analysis of clinical pathways.

How effective are clinical pathways with and without online peer-review? An analysis of bone metastases pathway in a large, integrated National Cancer Institute-Designated Comprehensive Cancer Center Network

PURPOSE

Clinical pathways are an important tool used to manage the quality in health care by standardizing processes. This study evaluated the impact of the implementation of a peer-reviewed clinical pathway in a large, integrated National Cancer Institute-Designated Comprehensive Cancer Center Network.

METHODS

In 2003, we implemented a clinical pathway for the management of bone metastases with palliative radiation therapy. In 2009, we required the entry of management decisions into an online tool that records pathway choices. The pathway specified 1 or 5 fractions for symptomatic bone metastases with the option of 10-14 fractions for certain clinical situations. The data were obtained from 13 integrated sites (3 central academic, 10 community locations) from 2003 through 2010.

RESULTS

In this study, 7905 sites were treated with 64% of courses delivered in community practice and 36% in academic locations. Academic practices were more likely than community practices to treat with 1-5 fractions (63% vs. 23%; p < 0.0001). The number of delivered fractions decreased gradually from 2003 to 2010 for both academic and community practices (p < 0.0001); however, greater numbers of fractions were selected more often in community practices (p < 0.0001). Using multivariate logistic regression, we found that a significantly greater selection of 1-5 fractions developed after implementation online pathway monitoring (2009) with an odds ratio of 1.2 (confidence interval, 1.1-1.4) for community and 1.3 (confidence interval, 1.1-1.6) for academic practices. The mean number of fractions also decreased after online peer review from 6.3 to 6.0 for academic (p = 0.07) and 9.4 to 9.0 for community practices (p < 0.0001).

CONCLUSION

This is one of the first studies to examine the efficacy of a clinical pathway for radiation oncology in an integrated cancer network. Clinical pathway implementation appears to be effective in changing patterns of care, particularly with online clinical peer review as a valuable aid to encourage adherence to evidence-based practice.

Using recommendation to support adaptive clinical pathways

Clinical pathways are among the main tools used to manage the quality in health-care concerning the standardization of care processes. This paper deals with a recommendation service to support adaptive clinical pathways. The proposed approach can guide physicians in clinical pathways by providing recommendations on possible next steps based on the measurement of the target patient status and medical knowledge from completed clinical cases. The efficiency and usability of the proposed method is validated by experiments referring to a real data set extracted from Electronic Patient Records. The experimental results indicate that the recommendation service can provide its users with advice rationales that remain consistent even when patient status has changed. This makes adaptive clinical pathways possible.

Hip fractures--a joint effort

More than 350,000 hip fractures occur in the United States every year, and the number will double by 2050 as baby boomers advance in age. Hip fractures remain one of the most common injuries of the geriatric cohort, where 9 of 10 patients with a hip fracture are 65 years of age or older and have multiple medical problems. A coordinated approach to care that emphasizes early ambulation, prevention of complications, and patient/family involvement is essential. This article describes the efforts of a interdisciplinary team to develop and implement a hip fracture protocol that directs the care of patients from admission in the emergency room to a planned discharge. The ideal process of care is driven by quality measures and evidence-based practice consisting of early medical screening, early surgical intervention and ambulation, physical therapy, deep vein thrombosis prophylaxis, and appropriate discharge planning.

Knowledge-based quality management and clinical pathways

OBJECTIVES

Although 65% of the hospitals in Taiwan claim to be applying the clinical pathway concept, most hospitals do not implement this concept effectively. The purpose of this study was to determine the reasons for the improper or inappropriate application of the clinical pathway design in hospitals.

METHODS

This study differs from other studies in clinical pathway design and application in that it seeks to resolve misunderstandings of the clinical pathway analysis that may have been generated by the responses to survey questionnaires. Therefore, in-depth interviews and Senge's system archetype have been used to ascertain the reasons why the use of a clinical pathway design has been ineffective. We also used the 4 dimensions of knowledge-based management proposed by Drucker to set up the knowledge-based clinical pathway. Thirteen experts used the Delphi method to construct 20 knowledge-based clinical pathway guidelines.

CONCLUSIONS

The application of knowledge- and management-based clinical pathway designs is recommended.

Improvements in Health Care for Patients Undergoing Thyroidectomy

OBJECTIVE

In this study, we evaluated the effect on cost and clinical outcome of the implementation of departmental subspecialization and a clinical care pathway for patients undergoing thyroidectomy.

METHODS

Subspecialization and a clinical thyroidectomy pathway were implemented in 2001 at the Department of Surgery, National University Hospital, Singapore. A total of 150 patients (Group A) who served as controls were compared with 143 patients who were managed after implementation of subspecialization and the clinical thyroidectomy pathway (Group B). Length of stay, postoperative complications and cost per patient were compared between the two groups.

RESULTS

The mean age was 46 years and females comprised 77% of all patients. The mean length of hospital stay was shorter in Group B (1.9 days) compared with Group A (3.3 days; p < 0.001). The mean hospital charges also fell significantly after implementation, at 3,524 dollars per patient in Group B compared with 3,929 dollars in Group A (p = 0.003). There was no difference in morbidity between the two groups (2.0% and 1.4% in Groups A and B, respectively).

CONCLUSION

This study confirms that length of hospital stay and hospital costs are effectively reduced through the combination of subspecialization and a clinical pathway for patients undergoing thyroidectomy. Subspecialty units and pathways reduce variation in patient care. This effectively leads to better-quality outcomes, more efficient discharge planning and improved cost-effectiveness of clinical services.

[Design and use of patient pathways in general surgery]

BACKGROUND

Clinical pathways are a new initiative intended to reduce costs while maintaining or even improving the quality of care. Based on treatment guidelines, patient pathways display an optimal sequence of staff actions in the preoperative, operative, and postoperative in- and outpatient treatment.

METHODS

In this study, patient pathways were developed for selected elective general surgical disease entities following a new modular approach. All elements of care and their direct costs to the hospital were identified. Multidisciplinary teams of physicians, nurses, and administrative staff constructed and implemented the patient pathways.

RESULTS

In the 1-year pilot phase, we developed and implemented 7 pathways with 16 subpathways: open herniorrhaphy, laparoscopic cholecystectomy and fundoplication, thyroidectomy, surgical treatment of diverticulitis and colon carcinoma and kidney transplantation.

CONCLUSIONS

Patient pathways combine the management of care, hospital processes, and costs in a new integrated concept. Patient pathways streamline and standardize care, facilitate communication, and contribute to cost control efforts.

Reduced Length of Stay by Implementation of a Clinical Pathway for Bariatric Surgery in an Academic Health Care Center

Bariatric surgery is being performed in increasing numbers in an era when reimbursements are being reduced. Academic health centers bear the responsibility for training surgeons to perform these operations yet must keep costs to a minimum and retain high quality. The UCLA Bariatric Surgery Program developed a clinical pathway for the pre- and postoperative management for gastric bypass patients to achieve these goals. Medical records for 182 consecutive gastric bypass patients were retrospectively reviewed before implementation of the pathway (Group I) during the fiscal year of 1998/1999. Data on average length of stay, average intensive care unit length of stay, average standard variable cost, percentage readmission rate, and percentage return to the operating room were collected. This information was compared with the data collected prospectively from 182 patients after implementation of the pathway in July of 1999 (Group II) during the fiscal year of 1999/2000. Hospital cost per admission was reduced by 40 per cent in Group II compared with Group I ( P < 0.02). The average length of stay was reduced from 4.05 days in Group I to 3.17 days in Group II ( P < 0.033). Overall readmission rate was decreased from 4.2 per cent in Group I to 3.2 per cent in Group II ( P < 0.05). There were no differences in morbidities between both groups. The pathway reduced costs by reducing the hospital length of stay, intensive care unit utilization, and readmission rates. Quality was maintained as evidenced by a similar pattern of postoperative morbidities yet readmission rates were reduced. Our results indicate that implementation of a clinical pathway for bariatric surgery reduces cost and improves quality of care in an academic institution.

Protocols and guidelines in critical care: development and implementation

Variation in clinical management has been associated with suboptimal outcomes and increased costs. Guidelines, protocols, and clinical pathways have evolved as a strategy to standardize care, principally by limiting variation, thereby reducing complications, decreasing length of stay and improving outcomes. However, the nature of critical care makes it difficult to conduct blinded, randomized, and controlled clinical trials, the specific type of science required for evidenced-based medicine and guideline development. Areas in which ICU-based guidelines have been successful include, among others, sedation and neuromuscular blockade use, ventilator management, antibiotic selection, and vascular surgical interventions.

Implementation of a clinical pathway in management of the postoperative vestibular schwannoma patient

OBJECTIVE

The purpose of the study was to evaluate the effectiveness of a new clinical pathway in management of patients with postoperative vestibular schwannoma. The impact on duration of hospitalization and quality of care was evaluated.

STUDY DESIGN

The study was a retrospective review of 59 consecutive patients undergoing surgical intervention for vestibular schwannoma between January 1995 and July 1999.

METHODS

A new clinical pathway for management of postoperative vestibular schwannoma patients was implemented at The California Ear Institute at Stanford (Palo Alto, CA) in January 1995. All patients undergoing surgical intervention subsequent to initiation of the pathway were included in the study. Data including surgical approach, patient age, sex, and tumor size were included. Duration of hospitalization and postoperative complications were recorded. During the same time period, data for patients undergoing radiation therapy for vestibular schwannomas were evaluated for length of hospital stay and in-hospital complications. Data were compared with norms recorded in the literature for duration of hospitalization and complications following surgical intervention.

RESULTS

Fifty-nine patients underwent 35 middle fossa approaches and 24 translabyrinthine approaches to their tumors. The average patient age was 53 years; there were 34 female and 25 male patients. The average length of hospital stay was 3.83 days (SD = 1.4 days) with a range from 2 to 10 days. Postoperative complications were observed in 19% of patients, including eight (13%) cerebrospinal fluid (CSF) leaks, two requiring lumbar drains (3.4%); one hematoma (1.6%), one postoperative fever (1.6%), and one dural tear with associated hyponatremia (1.6%). These results compared favorably with previously recorded average hospital stays of 5.95 to 9.5 days 1,5-7 and CSF leak complication rates of 7% to 15%.9,10

CONCLUSIONS

Implementation of a clinical pathway for management of the patient with postoperative vestibular schwannoma improves efficiency of patient care, allowing decreased duration of hospitalization. This goal is achieved without increasing complication rates and, in our experience, actually improving the quality of clinical care. The cost-effectiveness of clinical pathways may become increasingly important in a managed care-driven environment.

Clinical pathways--can they be used in trauma care. An analysis of their ability to fit the patient

This study prospectively evaluated the appropriateness and ability of clinical pathways to fit trauma patients in five key conditions, severe head injury, fractured ribs, fractured pelvis, fractured femur and blunt abdominal trauma, who were admitted to a single Level 1 Trauma Centre, between February and July 1999. Each pathway consisted of 14 elements of care divided into observable outcomes. Failure to achieve an outcome resulted in a variance or deviation from the pathway, which was assessed by the number of non-applicable variances. Appropriateness of clinical pathways was assessed by the applicability index (the number of non-applicable variances divided by the potential variances). Critical mismatches occurred when non-applicable variances exceeded 50% of potential variances. 146 patients, with the mean age 41.9 years (S.D. 20.7), mean ISS 11.1 (S.D. 10.7) were enrolled; 18 with severe head injury, 59 with fractured ribs, 13 with fractured pelvis, 20 with fractured femur and 36 with blunt abdominal trauma. Critical mismatch occurred in seven patients. Applicability indexes were 87 for head, 93 for ribs, 92 for blunt abdominal trauma, 91 for femur and 92 for the pelvic pathway. Patient assessment, pain management, skin integrity and patient education were the most appropriate key elements of care, discharge planning, patient satisfaction, treatment and activity were least applicable. This study identified, for the first time, that clinical pathways are clinically appropriate for major trauma conditions.

The impact of a clinical pathway for gastric bypass surgery on resource utilization

BACKGROUND

Clinical pathways are believed to improve patient care and reduce costs. Our hypothesis was that a gastric bypass pathway would decrease hospital resource utilization and cost of care without adversely affecting patient care.

METHODS

The prepathway (Pre) group consisted of 16 gastric bypasses (6/98 to 3/99). The postpathway (Post) group includes 12 gastric bypass procedures performed after institution of the clinical pathway (4/99 to 12/99). The impact of the clinical pathway on hospital length of stay (LOS) and resource utilization was investigated. A comparison of costs was performed using cost/charge ratios. Hospital readmissions and postoperative complications were also examined.

RESULTS

Despite increased obesity/medical acuity of the Post group, hospital LOS decreased by 3 days (P < 0.0001). Total hospital costs decreased by over $1600/case (>15%). Postpathway savings were greatest for room and board (34%), supplies (41%), and lab/radiology costs (50%). An increase in OR costs (22%) was observed in the Post group. This was due to an increase in anesthesia time (epidural catheter placement) and equipment costs (ultrasonic shears). Despite reductions in hospital LOS and resource utilization, the complication rate (Pre 12%, Post 16%) was similar and two patients in each group required brief readmission.

CONCLUSIONS

A pathway for gastric bypass decreased hospital LOS and resource utilization. OR-related expenses account for 34-50% of total costs and must be monitored closely for surgical patients. The reduction in costs observed with this clinical pathway was not associated with an increase in postoperative complications or hospital readmission.

Managing patients with acute, nonvariceal gastrointestinal hemorrhage: development and effectiveness of a clinical care pathway

OBJECTIVES

To develop a clinical care pathway for the management of patients with acute upper or lower nonvariceal GI hemorrhage (GIH) who do not require immediate surgical intervention. To test the effectiveness and safety of the pathway in improving the efficiency of care for patients with acute GIH.

METHODS

A multidisciplinary team developed the evidence-based GIH clinical care pathway by consensus techniques. In a quasiexperimental design, pathway outcomes were measured prospectively during the first 8 months of pathway implementation, and compared to similar time periods in the 2 prior yr. Effectiveness measures were the number of patients <65 yr of age admitted for GIH and the hospital length of stay for all patients. Thirty-day safety outcomes were the rates of recurrent GIH, mortality, and readmission to hospital for any reason.

RESULTS

Of 368 patients studied after pathway implementation, 81 (22%) were managed as outpatients. The number of admissions for pathway patients <65 yr of age was significantly lower compared to 691 prepathway patients (p < 0.002). Mean length of stay (+/- 95% CI) for pathway inpatients was 3.5 (3.1, 3.9) days, compared to 5.3 (4.9, 5.7) and 4.6 (4.2, 5) days in the 2 prepathway yr, respectively (p < 0.001). Multivariable regression controlling for admission vital signs, comorbid conditions, age, and the etiology of GIH confirmed that admission after pathway implementation was an independent predictor of a reduced length of hospital stay. There were no significant between-year differences in the 30-day rates of recurrent GIH, mortality, or hospital readmission.

CONCLUSION

A multidisciplinary clinical care pathway may improve the efficiency of caring for patients with acute upper or lower nonvariceal GIH. Decreasing the number of admissions for GIH and reducing the hospital length of stay can be achieved without increasing the number of adverse outcomes.

Description of a multihospital process to develop a care path for the child with acute lymphoblastic leukemia

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

Strategies to improve compliance with evidence-based clinical management guidelines

BACKGROUND

Clinical management guidelines (CMGs) have been developed to standardize physician practices and ensure safe and cost-effective patient care. In June 1996, evidence-based CMGs were initiated at our urban Level I trauma center. This study compares physician compliance with two such CMGs before (PRE) and after (POST) the institution of continuous surveillance by a clinical resource manager.

STUDY DESIGN

For 2 months PRE resource manager surveillance hospital records were reviewed retrospectively for compliance with two CMGs. POST data were collected prospectively for 2 months by the resource manager, who alerted practitioners to deviance from CMGs to justify or document therapy alternatives. The CMGs studied addressed deep venous thrombosis and stress ulcer prophylaxis. "Under" or "over" therapy described that which fell short of or exceeded guidelines. Data were analyzed by chi-square; p < 0.05 defined statistical significance.

RESULTS

Compliance with the CMGs was 48% PRE and 74% POST (p=0.001). All noncompliant instances POST (and none PRE) were altered or justified. Deep venous thrombosis and ulcer "over" therapy was significantly higher PRE (19% versus 2%, p=0.003; 49% versus 19%, p=0.001), resulting in $22,760.35 in costs. There was no difference in pulmonary embolism or gastrointestinal bleed rate (1%) PRE to POST.

CONCLUSIONS

The use of a clinical resource manager empowered to monitor and coordinate physician behavior improves compliance with CMGs. Further study is warranted to validate resultant outcomes benefit, specifically cost-effectiveness and duration of the need for such a program.

Implementation of a clinical pathway decreases length of stay and cost for bowel resection

OBJECTIVE

To examine the effect of a clinical pathway for small and large bowel resection on cost and length of hospital stay.

SUMMARY BACKGROUND DATA

Clinical pathways are designed to streamline patient care delivery and maximize efficiency while minimizing cost. Theoretically, they should be most effective in commonly performed procedures, in which volume and familiarity are high.

METHODS

A clinical pathway to assist in the management of patients undergoing bowel resection was developed by a multidisciplinary team and implemented. Data about length of stay and cost was collected for all patients undergoing bowel resection 1 year before and 1 year after pathway implementation. Three groups were compared: patients undergoing bowel resection in the year prior to pathway implementation (prepathway), patients in the year after pathway implementation but not included on the pathway (nonpathway), and patients included in the pathway (pathway).

RESULTS

The mean cost per hospital stay was $19,997.35 +/- 1244.61 for patients in the prepathway group, $20,835.28 +/- 2286.26 for those in the nonpathway group, and $13,908.53 +/- 1113.01 for those in the pathway group (p < 0.05 vs. other groups). Mean postoperative length of stay was 9.98 +/- 0.62 days (prepathway), 9.68 +/- 0.88 days for (nonpathway), and 7.71 +/- 0.37 days (pathway) (p < 0.05 vs. other groups).

CONCLUSIONS

Implementation of the pathway produced significant decreases in length of stay and cost in the pathway group as compared to the prepathway group. These results support the further development of clinical pathways for general surgical procedures.