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Carr JR, Knox DB, Butler AM, Lum MM, Jacobs JR, Jephson AR, Jones BE, Brown SM, Dean NC. ICU Utilization After Implementation of Minor Severe Pneumonia Criteria in Real-Time Electronic Clinical Decision Support. Crit Care Med 2024; 52:e132-e141. [PMID: 38157205 PMCID: PMC10922756 DOI: 10.1097/ccm.0000000000006163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVES To determine if the implementation of automated clinical decision support (CDS) with embedded minor severe community-acquired pneumonia (sCAP) criteria was associated with improved ICU utilization among emergency department (ED) patients with pneumonia who did not require vasopressors or positive pressure ventilation at admission. DESIGN Planned secondary analysis of a stepped-wedge, cluster-controlled CDS implementation trial. SETTING Sixteen hospitals in six geographic clusters from Intermountain Health; a large, integrated, nonprofit health system in Utah and Idaho. PATIENTS Adults admitted to the hospital from the ED with pneumonia identified by: 1) discharge International Classification of Diseases , 10th Revision codes for pneumonia or sepsis/respiratory failure and 2) ED chest imaging consistent with pneumonia, who did not require vasopressors or positive pressure ventilation at admission. INTERVENTIONS After implementation, patients were exposed to automated, open-loop, comprehensive CDS that aided disposition decision (ward vs. ICU), based on objective severity scores (sCAP). MEASUREMENTS AND MAIN RESULTS The analysis included 2747 patients, 1814 before and 933 after implementation. The median age was 71, median Elixhauser index was 17, 48% were female, and 95% were Caucasian. A mixed-effects regression model with cluster as the random effect estimated that implementation of CDS utilizing sCAP increased 30-day ICU-free days by 1.04 days (95% CI, 0.48-1.59; p < 0.001). Among secondary outcomes, the odds of being admitted to the ward, transferring to the ICU within 72 hours, and receiving a critical therapy decreased by 57% (odds ratio [OR], 0.43; 95% CI, 0.26-0.68; p < 0.001) post-implementation; mortality within 72 hours of admission was unchanged (OR, 1.08; 95% CI, 0.56-2.01; p = 0.82) while 30-day all-cause mortality was lower post-implementation (OR, 0.71; 95% CI, 0.52-0.96; p = 0.03). CONCLUSIONS Implementation of electronic CDS using minor sCAP criteria to guide disposition of patients with pneumonia from the ED was associated with safe reduction in ICU utilization.
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Affiliation(s)
- Jason R Carr
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Daniel B Knox
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Allison M Butler
- Intermountain Healthcare Statistical Data Center, Salt Lake City, UT
| | | | - Jason R Jacobs
- Intermountain Healthcare, Enterprise Data Analytics, Salt Lake City, UT
| | - Al R Jephson
- Intermountain Healthcare, Enterprise Data Analytics, Salt Lake City, UT
| | - Barbara E Jones
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City, UT
- Salt Lake City Veterans Affairs Medical Center, Salt Lake City, UT
| | - Samuel M Brown
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Nathan C Dean
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City, UT
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Balthazar AK, Finkelstein JB, Williams V, Lee T, Lajoie D, Logvinenko T, Kim YJ, Chacko S, Borer JG, Lee RS. Enhanced Recovery After Surgery for an Uncommon Complex Urological Procedure: The Complete Primary Repair of Bladder Exstrophy. J Urol 2023; 210:696-703. [PMID: 37335023 PMCID: PMC10883646 DOI: 10.1097/ju.0000000000003593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/09/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE ERAS (enhanced recovery after surgery) protocols are designed to optimize perioperative care and expedite recovery. Historically, complete primary repair of bladder exstrophy has included postoperative recovery in the intensive care unit and extended length of stay. We hypothesized that instituting ERAS principles would benefit children undergoing complete primary repair of bladder exstrophy, decreasing length of stay. We describe implementation of a complete primary repair of bladder exstrophy-ERAS pathway at a single, freestanding children's hospital. MATERIALS AND METHODS A multidisciplinary team developed an ERAS pathway for complete primary repair of bladder exstrophy, which launched in June 2020 and included a new surgical approach that divided the lengthy procedure into 2 consecutive operative days. The complete primary repair of bladder exstrophy-ERAS pathway was continuously refined, and the final pathway went into effect in May 2021. Post-ERAS patient outcomes were compared with a pre-ERAS historical cohort (2013-2020). RESULTS A total of 30 historical and 10 post-ERAS patients were included. All post-ERAS patients had immediate extubation (P = .04) and 90% received early feeding (P < .001). The median intensive care unit and overall length of stay decreased from 2.5 to 1 days (P = .005) and from 14.5 to 7.5 days (P < .001), respectively. After final pathway implementation, there was no intensive care unit use (n=4). Postoperatively, no ERAS patient required escalation of care, and there was no difference in emergency department visits or readmissions. CONCLUSIONS Applying ERAS principles to complete primary repair of bladder exstrophy was associated with decreased variations in care, improved patient outcomes, and effective resource utilization. Although ERAS has typically been utilized for high-volume procedures, our study highlights that an enhanced recovery pathway is both feasible and adaptable to less common urological surgeries.
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Affiliation(s)
- Andrea K Balthazar
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Vivian Williams
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
| | - Ted Lee
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
| | - Debra Lajoie
- Surgical Programs, Boston Children's Hospital, Boston, Massachusetts
| | - Tanya Logvinenko
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
| | - Young-Jo Kim
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Sabeena Chacko
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph G Borer
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
| | - Richard S Lee
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
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3
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Smith S, Sapkaroski D, Brand M, Tran A, Zalcberg J, Stirling RG. Mapping the clinical care pathways for advanced stage non-small cell lung cancer patients in Victoria: A retrospective cohort study of supportive and palliative care. Nurs Health Sci 2023; 25:411-423. [PMID: 37562814 DOI: 10.1111/nhs.13044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 05/21/2023] [Accepted: 07/28/2023] [Indexed: 08/12/2023]
Abstract
The lung cancer Optimal Care Pathway recommends supportive care and palliative care integration throughout its various steps, with early referral to appropriate services improving the quality of life in advanced stage non-small cell lung cancer patients. Using Victorian Lung Cancer Registry data and linked administrative datasets, this retrospective cohort study mapped clinical care pathways of 525 Stage III-IV non-small cell lung cancer patients in Victoria to 11 recommendations in the Optimal Care Pathway, identifying unwarranted variations in clinical care. Supportive care and palliative care delivery were further examined to understand the involvement and timing of specialist care teams. Our findings showed that palliative care utilization is highest at the time of treatment, despite recommendations that it should be provided early after diagnosis to improve patient outcomes and satisfaction. Early supportive care screening was observed in half the cohort and almost three-quarters of the patients had been presented at a multidisciplinary meeting. Multidisciplinary meeting presentations and supportive care provide an opportunity to improve communication about palliative care needs and integration into routine clinical practice, such as at the time of treatment planning.
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Affiliation(s)
- Shantelle Smith
- Cancer Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Population Health, Curtin University, Perth, Western Australia, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Daniel Sapkaroski
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
- Department of Radiation Therapy, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Margaret Brand
- Cancer Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anh Tran
- Cancer Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - John Zalcberg
- Cancer Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Robert G Stirling
- Cancer Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
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Rosende A, DiPette DJ, Martinez R, Brettler JW, Rodriguez G, Zuniga E, Ordunez P. HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings. Front Cardiovasc Med 2023; 10:1102482. [PMID: 37180772 PMCID: PMC10169833 DOI: 10.3389/fcvm.2023.1102482] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/27/2023] [Indexed: 05/16/2023] Open
Abstract
Background HEARTS in the Americas is the regional adaptation of the WHO Global HEARTS Initiative. It is implemented in 24 countries and over 2,000 primary healthcare facilities. This paper describes the results of a multicomponent, stepwise, quality improvement intervention designed by the HEARTS in the Americas to support advances in hypertension treatment protocols and evolution towards the Clinical Pathway. Methods The quality improvement intervention comprised: 1) the use of the appraisal checklist to evaluate the current hypertension treatment protocols, 2) a peer-to-peer review and consensus process to resolve discrepancies, 3) a proposal of a clinical pathway to be considered by the countries, and 4) a process of review, adopt/adapt, consensus and approval of the clinical pathway by the national HEARTS protocol committee. A year later, 16 participants countries (10 and 6 from each cohort, respectively) were included in a second evaluation using the HEARTS appraisal checklist. We used the median and interquartile scores range and the percentages of the maximum possible total score for each domain as a performance measure to compare the results pre and post-intervention. Results Among the eleven protocols from the ten countries in the first cohort, the baseline assessment achieved a median overall score of 22 points (ICR 18 -23.5; 65% yield). After the intervention, the overall score reached a median of 31.5 (ICR 28.5 -31.5; 93% yield). The second cohort of countries developed seven new clinical pathways with a median score of 31.5 (ICR 31.5 -32.5; 93% yield). The intervention was effective in three domains: 1. implementation (clinical follow-up intervals, frequency of drug refills, routine repeat blood pressure measurement when the first reading is off-target, and a straightforward course of action). 2. treatment (grouping all medications in a single daily intake and using a combination of two antihypertensive medications for all patients in the first treatment step upon the initial diagnosis of hypertension) and 3. management of cardiovascular risk (lower BP thresholds and targets based on CVD risk level, and the use of aspirin and statins in high-risk patients). Conclusion This study confirms that this intervention was feasible, acceptable, and instrumental in achieving progress in all countries and all three domains of improvement: implementation, blood pressure treatment, and cardiovascular risk management. It also highlights the challenges that prevent a more rapid expansion of HEARTS in the Americas and confirms that the main barriers are in the organization of health services: drug titration by non-physician health workers, the lack of long-acting antihypertensive medications, lack of availability of fixed-doses combination in a single pill and cannot use high-intensity statins in patients with established cardiovascular diseases. Adopting and implementing the HEARTS Clinical Pathway can improve the efficiency and effectiveness of hypertension and cardiovascular disease risk management programs.
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Affiliation(s)
- Andres Rosende
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, United States
| | - Donald J. DiPette
- School of Medicine Columbia, University of South Carolina, Columbia, SC, United States
| | - Ramon Martinez
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, United States
| | - Jeffrey W. Brettler
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
- Southern California Permanente Medical Group, Los Angeles, CA, United States
| | - Gonzalo Rodriguez
- Consultant for HEARTS in the Americas, PAHO/WHO Office in Argentina, Buenos Aires, Argentina
| | - Eric Zuniga
- Antofagasta Health Service, University of Antofagasta, Antofagasta, Chile
| | - Pedro Ordunez
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, United States
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Ariza M, Martin S, Dusenne M, Darmon D, Schuers M. Management of patients with chronic kidney disease: a French medical centre database analysis. Fam Pract 2023:cmad004. [PMID: 36708191 DOI: 10.1093/fampra/cmad004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE(S) Chronic kidney disease (CKD) is an insidious disease that requires early nephroprotective measures to delay progression to end-stage kidney disease. The objective of this study was to describe the management of patients with CKD in primary care, including clinical and biological monitoring and prescribed treatments. A retrospective, single-centre study was conducted on adult patients who were treated in the Maison de Neufchâtel (France) between 2012 and 2017 at least once a year. The inclusion criteria were 2 estimated glomerular filtration rate (eGFR) measurements <60 mL/min more than 3 months apart. Two subgroups were constituted according to whether CKD was coded in the electronic medical records (EMRs). RESULTS A total of 291 (6.7%, CI95% 5.9-7.4) patients with CKD were included. The mean eGFR was 51.0 ± 16.4 mL/min. Hypertension was the most frequent health problem reported (n = 93, 32%). Nephrotective agents were prescribed in 194 (66.7%) patients, non-steroidal anti-inflammatory drugs (NSAIDs) in 22 (8%) patients, and proton-pump inhibitors (PPIs) in 147 (47%) patients. CKD coding in EMRs was associated with dosage of natraemia (n = 34, 100%, P < 0.01), albuminuria (n = 20, 58%, P < 0.01), vitamin D (n = 14, 41%, P < 0.001), and phosphorus (n = 11, 32%, P < 0.001). Eighty-one patients (31.5%) with low eGFR without an entered code for CKD were prescribed an albuminuria dosage. Clinical monitoring could not be analysed due to poor coding. CONCLUSION This pilot study reinforces the hypothesis that CKD is underscreened and undermanaged. More systematic coding of medical information in EMRs and further studies on medical centre databases should improve primary care practices.
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Affiliation(s)
- Matthieu Ariza
- University of Picardy Jules Verne, Department of General Medicine, Amiens, France
| | | | | | - David Darmon
- University of Côte d'Azur, RETINES, Department of Teaching and Research in General Medicine, Nice, France
| | - Matthieu Schuers
- Department of General Medicine of Rouen, University of Rouen, Rouen, France
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Abstract
Severe mental illnesses, such as schizophrenia or bipolar disorder, affect ≈1% of the population who, as a group, experience significant disadvantage in terms of physical health and reduced life expectancy. In this review, we explore the interaction between race, ethnicity, severe mental illness, and cardiovascular disease, with a focus on cardiovascular care pathways. Finally, we discuss strategies to investigate and address disparities in cardiovascular care for patients with severe mental illness.
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Affiliation(s)
- Kevin O'Gallagher
- British Heart Foundation Centre of Research ExcellenceKing’s College LondonLondonUnited Kingdom
- King’s College Hospital NHS Foundation TrustLondonUnited Kingdom
| | - James TH. Teo
- King’s College Hospital NHS Foundation TrustLondonUnited Kingdom
- Institute of Psychiatry, Psychology and NeuroscienceKing’s College LondonLondonUnited Kingdom
| | - Ajay M. Shah
- British Heart Foundation Centre of Research ExcellenceKing’s College LondonLondonUnited Kingdom
- King’s College Hospital NHS Foundation TrustLondonUnited Kingdom
| | - Fiona Gaughran
- Institute of Psychiatry, Psychology and NeuroscienceKing’s College LondonLondonUnited Kingdom
- South London and Maudsley NHS Foundation TrustLondonUnited Kingdom
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Caparó-Zamalloa C, Velásquez-Rimachi V, Mori N, Dueñas-Pacheco WI, Huerta-Rosario A, Farroñay-García C, Molina RA, Alva-Díaz C. Clinical Pathway for the Diagnosis and Management of Patients With Relapsing-Remitting Multiple Sclerosis: A First Proposal for the Peruvian Population. Front Neurol 2021; 12:667398. [PMID: 34744956 PMCID: PMC8567844 DOI: 10.3389/fneur.2021.667398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 09/09/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Relapsing–remitting multiple sclerosis (RRMS) is a subtype of degenerative inflammatory demyelinating disease of multifactorial origin that affects the central nervous system and leads to multifocal neurological impairment. Objectives: To develop a clinical pathway (CP) for the management of Peruvian patients with RRMS. Methods: First, we performed a literature review using Medline, Embase, Cochrane, ProQuest, and Science direct. Then, we structured the information as an ordered and logical series of five topics in a defined timeline: (1) How should MS be diagnosed? (2) How should a relapse be treated? (3) How should a DMT be initiated? (4) How should each DMT be used? and (5) How should the patients be followed? Results: The personnel involved in the care of patients with RRMS can use a series of flowcharts and diagrams that summarize the topics in paper or electronic format. Conclusions: We propose the first CP for RRMS in Peru that shows the essential steps for diagnosing, treating, and monitoring RRMS patients based on an evidence-based medicine method and local expert opinions. This CP will allow directing relevant clinical actions to strengthen the multidisciplinary management of RRMS in Peru.
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Affiliation(s)
- César Caparó-Zamalloa
- Basic Research Center in Dementias and Central Nervous System Demyelinating Diseases, Instituto Nacional de Ciencias Neurológicas, Lima, Peru.,Neurosonología, Clínica Delgado, Lima, Peru.,Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Victor Velásquez-Rimachi
- Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Lima, Peru.,Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru.,Grupo de Investigación Neurociencia, Efectividad Clínica y Salud Pública, Universidad Científica del Sur, Lima, Peru
| | - Nicanor Mori
- Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Lima, Peru.,Servicio de Neurología, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigación (OADI), Hospital Daniel Alcides Carrión, Callao, Peru
| | | | - Andrely Huerta-Rosario
- Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru.,Grupo de Investigación Neurociencia, Efectividad Clínica y Salud Pública, Universidad Científica del Sur, Lima, Peru.,Facultad de Medicina Hipólito Unanue, Universidad Nacional Federico Villarreal, Lima, Peru
| | - Chandel Farroñay-García
- Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru.,Instituto Nacional de Salud (INS), Lima, Peru
| | - Roberto A Molina
- Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru.,Grupo de Investigación Neurociencia, Efectividad Clínica y Salud Pública, Universidad Científica del Sur, Lima, Peru.,Servicio de Neurología, Hospital Nacional María Auxiliadora, Lima, Peru
| | - Carlos Alva-Díaz
- Grupo de Investigación Neurociencia, Efectividad Clínica y Salud Pública, Universidad Científica del Sur, Lima, Peru
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Talan DA, Mower WR, Lovecchio FA, Rothman RE, Steele MT, Keyloun K, Gillard P, Copp R, Moran GJ. Pathway with single-dose long-acting intravenous antibiotic reduces emergency department hospitalizations of patients with skin infections. Acad Emerg Med 2021; 28:1108-1117. [PMID: 33780567 PMCID: PMC8597095 DOI: 10.1111/acem.14258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 03/12/2021] [Accepted: 03/25/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Emergency department (ED) patients with serious skin and soft tissue infections (SSTIs) are often hospitalized to receive intravenous (IV) antibiotics. Appropriate patients may avoid admission following a single-dose, long-acting IV antibiotic. METHODS We conducted a preintervention versus postintervention design trial at 11 U.S. EDs comparing hospitalization rates under usual care to those using a clinical pathway that included a single IV dalbavancin dose. We enrolled adults with cellulitis, abscess, or wound infection with an infected area of ≥75 cm2 without other indications for hospitalization. Clinical pathway participants discharged from the ED received a 24-hour follow-up telephone call and had a 48- to 72-hour in-person visit. We hypothesized that, compared to usual care, the clinical pathway would result in a significant reduction in the initial hospitalization rate. RESULTS Of 156 and 153 participants in usual care and clinical pathway periods, median infection areas were 255.0 (interquartile range [IQR] = 150.0 to 500.0) cm2 and 289.0 (IQR = 161.3 to 555.0) cm2 , respectively. During their initial care, 60 (38.5%) usual care participants were hospitalized and 27 (17.6%) pathway participants were hospitalized (difference = 20.8 percentage points [PP], 95% confidence interval [CI] = 10.4 to 31.2 PP). Over 44 days, 70 (44.9%) usual care and 44 (28.8%) pathway participants were hospitalized (difference = 16.1 PP, 95% CI = 4.9 to 27.4 PP). CONCLUSIONS Implementation of an ED SSTI clinical pathway for patient selection and follow-up that included use of a single-dose, long-acting IV antibiotic was associated with a significant reduction in hospitalization rate for stable patients with moderately severe infections. Registration: NCT02961764.
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Affiliation(s)
- David A. Talan
- Ronald Reagan UCLA Medical CenterDavid Geffen School of Medicine at the University of California at Los Angeles Los Angeles CA USA
| | - William R. Mower
- Ronald Reagan UCLA Medical CenterDavid Geffen School of Medicine at the University of California at Los Angeles Los Angeles CA USA
| | - Frank A. Lovecchio
- Valleywise HealthASUUniversity of Arizona and Creighton College of Medicine Phoenix Arizona USA
| | - Richard E. Rothman
- Johns Hopkins Medical CenterJohns Hopkins School of Medicine Baltimore Maryland USA
| | - Mark T. Steele
- Truman Medical Center University of Missouri–Kansas City School of Medicine Kansas City Missouri USA
| | | | | | | | - Gregory J. Moran
- Olive ViewUCLA Medical CenterDavid Geffen School of Medicine at the University of California at Los Angeles Los Angeles California USA
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Abstract
BACKGROUND Protocol-driven therapy has been successful in managing patients with asthma on pediatric wards, but there is wide variability in ICU-level management that is often provider-dependent. This study aimed to determine if a standardized protocol for critical asthma treatment could improve clinical outcomes. METHODS A pre-intervention cohort consisting of subjects age 2-18 y, excluding patients with airway obstruction that was not felt to be due to asthma, who were admitted to the ICU for critical asthma. Demographics and data along with medication administration information were gathered using the hospital electronic medical record. A post-intervention cohort was obtained over 13 months in an identical manner. The primary end point was time on continuous albuterol. Subjects adhering to the protocol were examined as a subset. RESULTS 71 post-intervention subjects were compared with a historical cohort of 52 pre-intervention subjects over a similar time frame. There were no significant differences in demographic characteristics. Median time on continuous albuterol (14.4 h vs 8.1 h, P = .14) and secondary end points of median ICU length of stay (LOS), hospital LOS, and time from discontinuing continuous albuterol to transfer out of ICU were not significantly reduced in the post-intervention cohort. Overall adherence to the clinical protocol through completion was 42%. When comparing the pre-intervention cohort with the protocol-adherent subjects, significant reductions were seen in time on continuous albuterol (14.4 h vs 3.0 h, P < .001), ICU LOS (38.7 h vs 21.0 h, P < .001), and hospital LOS (2.8 d vs 1.7 d, P = .005). CONCLUSIONS Implementation of an asthma protocol in the pediatric ICU did not result in significant improvements in time on continuous albuterol or hospital and pediatric ICU LOS, likely due to low adherence to the protocol. However, in subjects who did adhere to the protocol there were significant reductions in the outcome measures.
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Affiliation(s)
- Nicholas M Kucher
- Division of Critical Care, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota.
| | | | - Gwenyth A Fischer
- Division of Critical Care, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | - Cynthia S Davey
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota
| | - Sameer Gupta
- Division of Critical Care, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
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10
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Anderson K, Bradford N, Edwards R, Nicholson J, Lockwood L, Clark JE. Improving management of fever in neutropenic children with cancer across multiple sites. Eur J Cancer Care (Engl) 2021; 30:e13413. [PMID: 33511731 DOI: 10.1111/ecc.13413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 10/28/2020] [Accepted: 01/06/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of a clinical pathway in achieving antibiotic administration in less than 60 minutes for children with cancer, presenting with fever and neutropenia. Secondary objectives were to determine association between time to antibiotics (TTA) and other variables including fever duration, location of care and intravenous access types. METHODS Following introduction of the clinical pathway, we collected prospective data about management of all cases that did and did not use the pathway across multiple sites over 16 months. A follow-up audit was conducted after 12 months. RESULTS We evaluated a total of 453 presentations. Use of the clinical pathway was significantly associated with achieving TTA in less than 60 minutes (RR 0.69, 95% CI 0.56-0.85, p = <0.001). Despite varying use of the pathway over time, the median time to antibiotics was achieved in both the initial study period (57 minutes) and sustained at follow-up (60 minutes). TTA was also associated with types of intravenous access device and location of care and with length of stay. We did not find any association between TTA and any other variables. CONCLUSION Clinical pathways improve fever management in this patient cohort. Ongoing education and auditing to identify factors which impact processes of care are necessary.
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Affiliation(s)
- Katrina Anderson
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Natalie Bradford
- Cancer and Palliative Care Outcomes Centre and Centre for Children's Health Research, Queensland University of Technology, South Brisbane, Qld, Australia
| | - Rachel Edwards
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Jessica Nicholson
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Liane Lockwood
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Julia E Clark
- Infection Management and Prevention Service, Queensland Children's Hospital, South Brisbane, Qld, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, Australia
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11
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Qin S, Yang Y, Zhang HB, Zheng XH, Li HR, Wen J. Identification of CDK1 as a candidate marker in cutaneous squamous cell carcinoma by integrated bioinformatics analysis. Transl Cancer Res 2021; 10:469-478. [PMID: 35116276 PMCID: PMC8797450 DOI: 10.21037/tcr-20-2945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/12/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cutaneous squamous cell carcinoma (cSCC) is a relatively common cancer that accounts for nearly 50% of non-melanoma skin cancer cases. However, the genotypes that are linked with poor prognosis and/or high relapse rates and pathogenic mechanisms of cSCC are not fully understood. To address these points, three gene expression datasets were analyzed to identify candidate biomarker genes in cSCC. METHODS The GSE117247, GSE32979, and GSE98767 datasets comprising a total of 32 cSCC samples and 31 normal skin tissue samples were obtained from the National Center for Biotechnology Information Gene Expression Omnibus database. Differentially expressed genes (DEGs) were identified and underwent pathway enrichment analyses with the Gene Ontology and Kyoto Encyclopedia of Genes and Genomes (KEGG). A putative DEG protein-protein interaction (PPI) network was also established that included hub genes. The expression of CDK1, MAD2L1, BUB1 ans CDC20 were examined in the study. RESULTS A total of 335 genes were identified, encompassing 219 found to be upregulated and 116 genes that were downregulated in cSCC, compared to normal tissue. Enriched functions of these DEGs were associated with Ephrin receptor signaling and cell division; cytosol, membrane, and extracellular exosomes; ATP-, poly(A) RNA-, and identical protein binding. We also established a PPI network comprising 332 nodes and identified KIF2C, CDC42, AURKA, MAD2L1, MYC, CDK1, FEN1, H2AFZ, BUB1, BUB1B, CKS2, CDC20, CCT2, ACTR2, ACTB, MAPK14, and HDAC1 as candidate hub genes. The expression of CDK1 are significantly higher in the cSCC tissues than that in normal skin. CONCLUSIONS The DEGs identified in this study are potential therapeutic targets and biomarkers for cSCC. CDK1 is a gene closely related to the occurrence and development of cSCC, which may play an important role. Bioinformatics analysis shows that it is involved in the important pathway of the pathogenesis of cSCC, and may be recognized and applied as a new biomarker in the future diagnosis and treatment of cSCC.
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Affiliation(s)
- Si Qin
- Department of Dermatology, Guangdong Second Provincial General Hospital, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yu Yang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Urology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Hao-Bin Zhang
- The Big Data Institute, Guangdong Create Environmental Technology Company Limited, Guangzhou, China
| | | | - Hua-Run Li
- Department of Dermatology, Guangdong Second Provincial General Hospital, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Ju Wen
- Department of Dermatology, Guangdong Second Provincial General Hospital, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
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12
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Dhaliwal JS, Goss F, Whittington MD, Bookman K, Ho PM, Zane R, Wiler J. Reduced admission rates and resource utilization for chest pain patients using an electronic health record-embedded clinical pathway in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:1602-1613. [PMID: 33392569 PMCID: PMC7771814 DOI: 10.1002/emp2.12308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Assess the impact of an electronic health record (EHR)-embedded clinical pathway (ePATH) as compared to a paper-based clinical decision support tool on outcomes for patients presenting to the emergency department (ED) with suspected acute coronary syndrome (ACS). METHODS A retrospective, quasi-experimental study using difference-in-differences and interrupted time series specifications to evaluate the impact of an EHR-embedded clinical pathway between April 2013 and July 2017. The intervention was implemented in February 2016 at a large academic tertiary hospital and compared to a local community hospital without the intervention. Eligible patients included adults (>18 years) presenting to the ED with chest pain who had a troponin ordered within 2 hours of arrival and a chest pain-related diagnosis. Patients with initial evidence of acute myocardial infarction were excluded. Primary outcomes included rates of admission and stress testing, hospital length of stay, and occurrence of major adverse cardiac events. RESULTS On average, there were 170 chest pain visits per month at the intervention site. The frequency of hospital admission (unadjusted 28.2% to 20.9%, P < 0.001) and stress testing (unadjusted 15.8% to 12.7%, P < 0.001) significantly declined after ePATH implementation. After comparison with the comparator site, ePATH was still associated with a significant reduction in hospital admissions (-10.79%, P < 0.001) and stress testing (-6.05%, P < 0.001). Hospital length of stay and rates of major adverse cardiac events did not significantly change. CONCLUSIONS Implementation of ePATH for patients presenting to the ED with chest pain was associated with safe reductions in hospital admission and stress testing. ePATH appears to be an effective tool for implementing evidence-based guidelines for ED patients with chest pain.
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Affiliation(s)
- Jasmeet S. Dhaliwal
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Foster Goss
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Melanie D. Whittington
- Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
- Data Science to Patient Value ProgramUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Kelly Bookman
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - P. Michael Ho
- Data Science to Patient Value ProgramUniversity of Colorado School of MedicineAuroraColoradoUSA
- Division of CardiologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Richard Zane
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- UCHealth CARE Innovation CenterAuroraColoradoUSA
| | - Jennifer Wiler
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- UCHealth CARE Innovation CenterAuroraColoradoUSA
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Nickinson ATO, Houghton JSM, Bridgwood B, Essop-Adam A, Nduwayo S, Payne T, Sayers RD, Davies RSM. The utilisation of vascular limb salvage services in the assessment and management of chronic limb-threatening ischaemia and diabetic foot ulceration: A systematic review. Diabetes Metab Res Rev 2020; 36:e3326. [PMID: 32314493 DOI: 10.1002/dmrr.3326] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/08/2019] [Accepted: 04/12/2020] [Indexed: 11/10/2022]
Abstract
Specialist vascular limb salvage services have gained prominence as a new model of care to help overcome barriers which exist in the management of patients with chronic limb-threatening ischaemia (CLTI) and/or diabetic foot ulceration (DFU). This systematic review aims to explore the nature of reported services, investigate their outcome in the management of CLTI/DFU, and assess the scope and quality of the evidence base to help make recommendations for future practice and research. A systematic search of MEDLINE, Embase, The Cochrane Library, Scopus and CINAHL, from 1st January 1995 to 18th January 2019, was performed. Specialist vascular limb salvage services were defined as those services conforming to the definition of "centres of excellence" within the 2019 Global Vascular Guidelines. A study protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019123325). In total, 2260 articles were screened, with 12 articles (describing 11 services) included in a narrative synthesis. All services ran akin to the "toe-and-flow" model, with a number of services having additional core input from diabetology, microbiology, allied health professionals and/or internal/vascular medicine. Methodological weaknesses were identified within the design of the included articles and only one was deemed of high quality. The inception of services was associated with improved rates of major amputation; however, no significant changes in minor amputation or mortality rates were identified. Further research should adopt more a standardised study design and outcomes measures in order to improve the quality of evidence within the literature.
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Affiliation(s)
- A T O Nickinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - J S M Houghton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - B Bridgwood
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - A Essop-Adam
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - S Nduwayo
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - T Payne
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - R D Sayers
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - R S M Davies
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
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Abstract
Hepatocellular carcinoma (HCC) is a malignant tumor with unsatisfactory prognosis. The abnormal genes expression is significantly associated with initiation and poor prognosis of HCC. The aim of the present study was to identify molecular biomarkers related to the initiation and development of HCC via bioinformatics analysis, so as to provide a certain molecular mechanism for individualized treatment of hepatocellular carcinoma.Three datasets (GSE101685, GSE112790, and GSE121248) from the GEO database were used for the bioinformatics analysis. Differentially expressed genes (DEGs) of HCC and normal liver samples were obtained using GEO2R online tools. Gene ontology term and Kyoto Encyclopedia of Gene and Genome (KEGG) pathway analysis were conducted via the Database for Annotation, Visualization, and Integrated Discovery online bioinformatics tool. The protein-protein interaction (PPI) network was constructed by the Search Tool for the Retrieval of Interacting Genes database and hub genes were visualized by Cytoscape. Survival analysis and RNA sequencing expression were conducted by UALCAN and Gene Expression Profiling Interactive Analysis.A total of 115 shared DEGs were identified, including 30 upregulated genes and 85 downregulated genes in HCC samples. P53 signaling pathway and cell cycle were the major enriched pathways for the upregulated DEGs whereas metabolism-related pathways were the major enriched pathways for the downregulated DEGs. The PPI network was established with 105 nodes and 249 edges and 3 significant modules were identified via molecular complex detection. Additionally, 17 candidate genes from these 3 modules were significantly correlated with HCC patient survival and 15 of 17 genes exhibited high expression level in HCC samples. Moreover, 4 hub genes (CCNB1, CDK1, RRM2, BUB1B) were identified for further reanalysis of KEGG pathway, and enriched in 2 pathways, the P53 signaling pathway and cell cycle pathway.Overexpression of CCNB1, CDK1, RRM2, and BUB1B in HCC samples was correlated with poor survival in HCC patients, which could be potential therapeutic targets for HCC.
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Affiliation(s)
- Quanquan Sun
- Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences, Beijing
- Department of Radiation Oncology
- Zhejiang Key Laboratory of Radiation Oncology, Zhejiang Cancer Hospital
| | - Peng Liu
- Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences, Beijing
- Department of Radiation Oncology
- Zhejiang Key Laboratory of Radiation Oncology, Zhejiang Cancer Hospital
| | - Bin Long
- Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences
- Department of Nuclear Medicine, Zhejiang Cancer Hospital, Key Laboratory of Head and Neck Cancer Translational Research of Zhejiang, Hangzhou, Zhejiang Province, People's Republic of China
| | - Yuan Zhu
- Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences, Beijing
- Department of Radiation Oncology
- Zhejiang Key Laboratory of Radiation Oncology, Zhejiang Cancer Hospital
| | - Tongxin Liu
- Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences, Beijing
- Department of Radiation Oncology
- Zhejiang Key Laboratory of Radiation Oncology, Zhejiang Cancer Hospital
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15
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Barrett J, Turner B, Silva S, Zychowicz M. Clinical pathways on a mobile device. BMJ Evid Based Med 2020; 25:131-137. [PMID: 31719128 DOI: 10.1136/bmjebm-2019-111234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2019] [Indexed: 11/04/2022]
Abstract
Clinical pathways have been successfully implemented in the primary care setting in New Zealand, Australia and the UK. Despite wide adoption and decreased costs, these pathways have yet to translate evidence into clinical practice while also saving providers time-an important barrier for the translation of evidence at the point of care. The goal of this project was to determine if future development of a point-of-care mobile application should be undertaken with design principles using the theoretical framework of Hick's law. Three new-to-practice providers participated in three plan-do-study-act cycles using these pathways installed on mobile devices to determine if they were a feasible, efficient and useful method to implement evidence. The project was a success with all three participants wishing to continue using the pathways after project completion. Participants felt the digital clinical pathways were the next evolution of the popular UpToDate software platform and helped them apply the latest evidence better than other available tools. While these results are promising, there were also limitations. Participants felt the lack of chart integration coupled with time constraints made full integration challenging and suggested launching the platform using a variety of delivery systems. The project's findings suggest that future application development using the developed design principles would be worth further consideration. If this mobile application ultimately proved successful, the application framework could be implemented on a larger scale, thus improving patient outcomes and saving providers time.
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Affiliation(s)
| | | | - Susan Silva
- Duke University, Durham, North Carolina, USA
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16
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Aeyels D, Bruyneel L, Seys D, Sinnaeve PR, Sermeus W, Panella M, Vanhaecht K. Better hospital context increases success of care pathway implementation on achieving greater teamwork: a multicenter study on STEMI care. Int J Qual Health Care 2020; 31:442-448. [PMID: 30256962 DOI: 10.1093/intqhc/mzy197] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 07/16/2018] [Accepted: 09/05/2018] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To evaluate whether hospital context influences the effect of care pathway implementation on teamwork processes and output in STEMI care. DESIGN A multicenter pre-post intervention study. SETTING Eleven acute hospitals. PARTICIPANTS Cardiologists-in-chief, nurse managers, quality staff, quality managers and program managers reported on hospital context. Teamwork was rated by professional groups (medical doctors, nurses, allied health professionals, other) in the following departments: emergency room, catheterization lab, coronary care unit, cardiology ward and rehabilitation. INTERVENTION Care pathway covering in-hospital care from emergency services to rehabilitation. MAIN OUTCOME MEASURES Hospital context was measured by the five dimensions of the Model for Understanding Success in Quality: microsystem, quality improvement team, quality improvement support, high-level organization, external environment. Teamwork process measures reflected teamwork between professional groups within departments and teamwork between departments. Teamwork output was measured through the level of organized care. Two-level regression analysis accounted for clustering of respondents within hospitals and assessed the influence of hospital context on the impact of care pathway implementation on teamwork. RESULTS Care pathway implementation significantly improved teamwork processes both between professional groups (P < 0.001) and between departments (P < 0.001). Teamwork output also improved (P < 0.001). The effect of care pathway implementation on teamwork was more pronounced when the quality improvement team and quality improvement support and capacity were more positively reported on. CONCLUSIONS Hospitals can leverage the effect of quality improvement interventions such as care pathways by evaluating and improving aspects of hospital context.
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Affiliation(s)
- Daan Aeyels
- Leuven Institute for Healthcare Policy, University of Leuven, Leuven, Belgium
| | - Luk Bruyneel
- Leuven Institute for Healthcare Policy, University of Leuven, Leuven, Belgium.,Department of Quality Management, University Hospitals Leuven, Leuven, Belgium
| | - Deborah Seys
- Leuven Institute for Healthcare Policy, University of Leuven, Leuven, Belgium
| | | | - Walter Sermeus
- Leuven Institute for Healthcare Policy, University of Leuven, Leuven, Belgium
| | - Massimiliano Panella
- Department of Clinical and Experimental Medicine, Amedeo Avogadro University of Eastern Piedmont, Vercelli, Italy
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, University of Leuven, Leuven, Belgium.,Department of Quality Management, University Hospitals Leuven, Leuven, Belgium
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17
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Fitzgerald JA, Curry J, Olde Meierink A, Cully A. Putting the consumer in the driver's seat: A visual journey through the Australian health-care system as experienced by people living with dementia and their carers. Australas J Ageing 2020; 38 Suppl 2:46-52. [PMID: 31496060 DOI: 10.1111/ajag.12691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 05/20/2019] [Accepted: 05/23/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To better understand the individual journeys of people living with dementia and their carers through the Australian health-care system. METHODS Stories were collected from 25 participants, through five face-to-face workshops, across Australia. This produced 18 visual storyboards and a range of opportunities for improvement, which were then synthesised into an aggregated "ideal-journey" model. RESULTS Several issues were identified: long lead times to diagnosis; diverse experiences of treatment and support; and little coordination of care or thought for its impact on the consumer. Information about services, their purpose and eligibility criteria was difficult to obtain, and potential care pathways were largely unexplained. Much of the carer support received was reactive rather than proactive. CONCLUSIONS A better understanding of the current health-care pathway of dementia is essential for the design and delivery of future health-care services. It is vital to include the consumer voice in future research and allocation of health-care resources.
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Affiliation(s)
- Janna Anneke Fitzgerald
- Department of Business Strategy and Innovation, Griffith University, Gold Coast, Queensland, Australia
| | - Joanne Curry
- Department of Business Strategy and Innovation, Griffith University, Gold Coast, Queensland, Australia.,DXC Technology, Sydney, Australia
| | - Angelique Olde Meierink
- Department of Business Strategy and Innovation, Griffith University, Gold Coast, Queensland, Australia
| | - Ashley Cully
- Department of Business Strategy and Innovation, Griffith University, Gold Coast, Queensland, Australia
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18
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Vidale S, Agostoni EC. Organizing Healthcare for Optimal Acute Ischemic Stroke Treatment. J Clin Neurol 2020; 16:183-190. [PMID: 32319234 PMCID: PMC7174131 DOI: 10.3988/jcn.2020.16.2.183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/17/2019] [Accepted: 11/19/2019] [Indexed: 12/12/2022] Open
Abstract
Stroke is a major health-care problem that represents a leading cause of death and also the top cause of disability in adulthood. In recent years there has been a significant paradigm shift in treatments for acute ischemic stroke to favor earlier reperfusion therapy, mainly using the systemic infusion of recombinant tissue plasminogen activator. Subsequent trials found that combining this treatment with endovascular therapy was effective in selected patients. The increased complexity of acute stroke treatments has resulted in a substantial reorganization of stroke care. This review reports on the evolution of acute ischemic stroke treatment and describes the main organizational models based on the hub-and-spoke system. The lack of evidence for comparisons of the effectiveness of different paradigms means that some decision-analysis models predicting the best organizational pathways are also reported, with a particular emphasis on the workflow timing in the prehospital and in-hospital settings. Major benchmarks and performance measures are also reported, focusing on the timing of interventions and rates of process indicators. Finally, future directions are illustrated, including using telemedicine for stroke, mobile stroke units, and artificial intelligence and automated machines to produce software for detecting large-vessel occlusion.
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Affiliation(s)
- Simone Vidale
- Department of Neurology, Infermi Hospital, Rimini, Italy.
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19
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Abstract
PURPOSE The typical mean length of stay following robot-assisted laparoscopic prostatectomy is 24 to 48 hours. We began routinely offering same day discharge from the hospital after robot-assisted laparoscopic prostatectomy. We evaluated the success rate, safety and cost implications in what is to our knowledge the only large series of same day discharge to date. MATERIALS AND METHODS Beginning in September 2016 all patients were given the option of same day discharge without it being mandated. After allowing 3 months to solidify the protocol we evaluated our prospective database for the next 500 patients. RESULTS Of the 500 consecutive men who underwent robot-assisted laparoscopic prostatectomy performed by 1 surgeon in 18 months 246 (49.2%) were discharged home the day of surgery and all of the remaining 254 were discharged the next day for a mean 0.51-day length of stay. Mean patient age was 62 years (range 42 to 81) and mean body mass index was 29.7 kg/m2 (range 20 to 53). Of the patients 34 (6.8%) had a Clavien-Dindo grade I-III complication within 90 days but there were no grade IV-V complications. Only 5 patients (1%) required an emergency department visit and only 8 (1.6%) required readmission. Only 1 of the patients who elected same day discharge was rehospitalized and only 1 presented to the emergency department. The estimated charge for an overnight stay at our institution is $2,109. The approximate reduction in charges was $518,814 during 18 months ($345,876 per year) with no increased cost due to emergency department visits or hospital readmissions compared with that of overnight patients. In the most recent 100 patients the rate of same day discharge improved to 65%. CONCLUSIONS Same day discharge following robot-assisted laparoscopic prostatectomy can be safely routinely offered with no increase in readmissions or emergency visits. It may lead to significant savings in health care costs.
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20
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Declarador N, Ramason R, Tay L, Chan WLW, Kwek EBK. Beyond comanaged inpatient care to community integration: Factors leading to surgical delay in hip fractures and their associated outcomes. J Orthop Surg (Hong Kong) 2019; 26:2309499018783909. [PMID: 29954285 DOI: 10.1177/2309499018783909] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Early surgery for older adults with hip fracture has been shown to improve outcomes. We aim to study the factors contributing to delay in surgery (defined as surgery performed more than 48 h after admission) and its associated outcomes in a tertiary hospital in Singapore with an integrated hip fracture program. METHODS This is a prospective cohort study of hip fracture patients aged more than 60 years over 1 year. We collected data on demographics, premorbid mobility and functional status, time to surgery, postoperative complications, and inhospital mortality. Mortality data and functional performance were reviewed at 1 year. RESULTS High American Society of Anaesthesiologists score independently predicted delay in surgery (odd ratio (OR) = 9.52, 95% confidence interval (CI): 1.69-53.68). Delayed surgery was significantly associated with longer length of stay (median 12.8 days with interquartile range (IQR) 9.7-17.6 days vs. 8.35 days with IQR 5.9-10.9 days, p < 0.01). Surgery within 48 h significantly reduced functional decline (Modified Barthel Index change -3.89 ± 17.23 vs. -9.29 ± 20.30, p = 0.01) and 1-year mortality (3.5% vs. 9.3%, p = 0.03). Surgical delay was an independent risk factor for early postoperative complications (OR = 3.21, 95% CI: 1.21-8.49), and patients were significantly less likely to return to premorbid mobility at 1 year (OR = 0.62, 95% CI: 0.39-0.97). CONCLUSIONS Delayed hip fracture surgery in older adults is associated with worse short- and long-term outcomes, including early postoperative complications and poorer functional recovery.
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Affiliation(s)
| | - Rani Ramason
- 1 Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore
| | - Laura Tay
- 2 Department of General Medicine (Geriatric Medicine), Sengkang Health, Singapore
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Neame MT, Chacko J, Surace AE, Sinha IP, Hawcutt DB. A systematic review of the effects of implementing clinical pathways supported by health information technologies. J Am Med Inform Assoc 2019; 26:356-363. [PMID: 30794311 PMCID: PMC7647175 DOI: 10.1093/jamia/ocy176] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 11/22/2018] [Accepted: 11/28/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Health information technology (HIT) interventions include electronic patient records, prescribing, and ordering systems. Clinical pathways are multidisciplinary plans of care that enable the delivery of evidence-based healthcare. Our objective was to systematically review the effects of implementing HIT-supported clinical pathways. MATERIALS AND METHODS A systematic review protocol was developed including Medline, Embase, and CENTRAL database searches. We recorded data relating to study design, participants, intervention, and outcome characteristics and formally assessed risk of bias. RESULTS Forty-four studies involving more than 270 000 patients were included. Investigation methodologies included before-after (n = 16, 36.4%), noncomparative (n = 14, 31.8%), interrupted time series (n = 5, 11.4%), retrospective cohort (n = 4, 9.1%), cluster randomized (n = 2, 4.5%), controlled before-after (n = 1, 2.3%), prospective case-control (n = 1, 2.3%), and prospective cohort (n = 1, 2.3%) study designs. Clinical decision support (n = 25, 56.8%), modified electronic documentation (n = 23, 52.3%), and computerized provider order entry (n = 23, 52.3%) were the most frequently utilized HIT interventions. The majority of studies (n = 38, 86.4%) reported benefits associated with HIT-supported pathways. These included reported improvements in objectively measured patient outcomes (n = 15, 34.1%), quality of care (n = 29, 65.9%), and healthcare resource utilization (n = 10, n = 22.7%). DISCUSSION Although most studies reported improvements in outcomes, the strength of evidence was limited by the study designs that were utilized. CONCLUSIONS Ongoing evaluations of HIT-supported clinical pathways are justified but would benefit from study designs that report key outcomes (including adverse events) and minimize the risk of bias.
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Affiliation(s)
- Matthew T Neame
- Global Digital Exemplar Programme, Alder Hey Children’s Hospital, Liverpool, United Kingdom
| | - Jerry Chacko
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Anna E Surace
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Ian P Sinha
- Global Digital Exemplar Programme, Alder Hey Children’s Hospital, Liverpool, United Kingdom
| | - Daniel B Hawcutt
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
- Alder Hey Clinical Research Facility, National Institute of Health Research Alder Hey Clinical Research Facility, Liverpool, United Kingdom
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22
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Cook DA, Pankratz VS, Pencille LJ, Dupras DM, Linderbaum JA, Wilkinson JM. Associations Among Practice Variation, Clinician Characteristics, and Care Algorithm Usage: A Multispecialty Vignette Study. Am J Med Qual 2019; 34:596-606. [PMID: 30698036 DOI: 10.1177/1062860618824992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective was to quantitatively evaluate clinician characteristics associated with unwarranted practice variation, and how clinical care algorithms influence this variation. Participants (142 physicians, 53 nurse practitioners, and 9 physician assistants in family medicine, internal medicine, and cardiology) described their management of 4 clinical vignettes, first based on their own practice (unguided), then using care algorithms (guided). The authors quantitatively estimated variation in management. Cardiologists demonstrated 17% lower variation in unguided responses than generalists (fold-change 0.83 [95% confidence interval (CI) 0.68, 0.97]), and those who agreed that practice variation can realistically be reduced had 16% lower variation than those who did not (fold-change 0.84 [CI, 0.71, 0.99]). A 17% reduction in variation was observed for guided responses compared with baseline (unguided) responses (fold-change 0.83 [CI, 0.76, 0.90]). Differences were otherwise similar across clinician subgroups and attitudes. Unwarranted practice variation was similar across most clinician subgroups. The authors conclude that care algorithms can reduce variation in management.
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Affiliation(s)
| | - V Shane Pankratz
- University of New Mexico Health Sciences Center, Albuquerque, NM
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Cook DA, Sorensen KJ, Linderbaum JA, Pencille LJ, Rhodes DJ. Information needs of generalists and specialists using online best-practice algorithms to answer clinical questions. J Am Med Inform Assoc 2018; 24:754-761. [PMID: 28339685 DOI: 10.1093/jamia/ocx002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 12/31/2016] [Indexed: 11/13/2022] Open
Abstract
Objective To better understand clinician information needs and learning opportunities by exploring the use of best-practice algorithms across different training levels and specialties. Methods We developed interactive online algorithms (care process models [CPMs]) that integrate current guidelines, recent evidence, and local expertise to represent cross-disciplinary best practices for managing clinical problems. We reviewed CPM usage logs from January 2014 to June 2015 and compared usage across specialty and provider type. Results During the study period, 4009 clinicians (2014 physicians in practice, 1117 resident physicians, and 878 nurse practitioners/physician assistants [NP/PAs]) viewed 140 CPMs a total of 81 764 times. Usage varied from 1 to 809 views per person, and from 9 to 4615 views per CPM. Residents and NP/PAs viewed CPMs more often than practicing physicians. Among 2742 users with known specialties, generalists ( N = 1397) used CPMs more often (mean 31.8, median 7 views) than specialists ( N = 1345; mean 6.8, median 2; P < .0001). The topics used by specialists largely aligned with topics within their specialties. The top 20% of available CPMs (28/140) collectively accounted for 61% of uses. In all, 2106 clinicians (52%) returned to the same CPM more than once (average 7.8 views per topic; median 4, maximum 195). Generalists revisited topics more often than specialists (mean 8.8 vs 5.1 views per topic; P < .0001). Conclusions CPM usage varied widely across topics, specialties, and individual clinicians. Frequently viewed and recurrently viewed topics might warrant special attention. Specialists usually view topics within their specialty and may have unique information needs.
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Affiliation(s)
- David A Cook
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, USA.,Mayo Clinic Online Learning, Mayo Clinic College of Medicine, Rochester, MN, USA.,Division of General Internal Medicine, Mayo Clinic
| | | | - Jane A Linderbaum
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, USA.,Department of Cardiovascular Diseases, Mayo Clinic
| | - Laurie J Pencille
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, USA.,Center for the Science of Health Care Delivery, Mayo Clinic
| | - Deborah J Rhodes
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, USA.,Division of Preventive Medicine, Mayo Clinic
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24
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Than MP, Pickering JW, Dryden JM, Lord SJ, Aitken SA, Aldous SJ, Allan KE, Ardagh MW, Bonning JWN, Callender R, Chapman LRE, Christiansen JP, Cromhout APJ, Cullen L, Deely JM, Devlin GP, Ferrier KA, Florkowski CM, Frampton CMA, George PM, Hamilton GJ, Jaffe AS, Kerr AJ, Larkin GL, Makower RM, Matthews TJE, Parsonage WA, Peacock WF, Peckler BF, van Pelt NC, Poynton L, Richards AM, Scott AG, Simmonds MB, Smyth D, Thomas OP, To ACY, Du Toit SA, Troughton RW, Yates KM. ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome): A Study of Cross-System Implementation of a National Clinical Pathway. Circulation 2017; 137:354-363. [PMID: 29138293 DOI: 10.1161/circulationaha.117.031984] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 10/10/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Efforts to safely reduce length of stay for emergency department patients with symptoms suggestive of acute coronary syndrome (ACS) have had mixed success. Few system-wide efforts affecting multiple hospital emergency departments have ever been evaluated. We evaluated the effectiveness of a nationwide implementation of clinical pathways for potential ACS in disparate hospitals. METHODS This was a multicenter pragmatic stepped-wedge before-and-after trial in 7 New Zealand acute care hospitals with 31 332 patients investigated for suspected ACS with serial troponin measurements. The implementation was a clinical pathway for the assessment of patients with suspected ACS that included a clinical pathway document in paper or electronic format, structured risk stratification, specified time points for electrocardiographic and serial troponin testing within 3 hours of arrival, and directions for combining risk stratification and electrocardiographic and troponin testing in an accelerated diagnostic protocol. Implementation was monitored for >4 months and compared with usual care over the preceding 6 months. The main outcome measure was the odds of discharge within 6 hours of presentation RESULTS: There were 11 529 participants in the preimplementation phase (range, 284-3465) and 19 803 in the postimplementation phase (range, 395-5039). Overall, the mean 6-hour discharge rate increased from 8.3% (range, 2.7%-37.7%) to 18.4% (6.8%-43.8%). The odds of being discharged within 6 hours increased after clinical pathway implementation. The odds ratio was 2.4 (95% confidence interval, 2.3-2.6). In patients without ACS, the median length of hospital stays decreased by 2.9 hours (95% confidence interval, 2.4-3.4). For patients discharged within 6 hours, there was no change in 30-day major adverse cardiac event rates (0.52% versus 0.44%; P=0.96). In these patients, no adverse event occurred when clinical pathways were correctly followed. CONCLUSIONS Implementation of clinical pathways for suspected ACS reduced the length of stay and increased the proportions of patients safely discharged within 6 hours. CLINICAL TRIAL REGISTRATION URL: https://www.anzctr.org.au/ (Australian and New Zealand Clinical Trials Registry). Unique identifier: ACTRN12617000381381.
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Affiliation(s)
- Martin P Than
- Emergency Department (M.P.T., J.W.P., M.W.A., R.C., J.M.D., O.P.T., J.M.D.)
| | - John W Pickering
- Emergency Department (M.P.T., J.W.P., M.W.A., R.C., J.M.D., O.P.T., J.M.D.).,Department of Medicine, Christchurch Heart Institute, University of Otago, New Zealand (J.W.P., C.M.A.F., P.M.G., A.M.R., R.W.T.)
| | - Jeremy M Dryden
- Emergency Department (M.P.T., J.W.P., M.W.A., R.C., J.M.D., O.P.T., J.M.D.)
| | - Sally J Lord
- Department of Epidemiology and Medical Statistics, University of Notre Dame, Sydney Campus, New South Wales, Australia (S.J.L.)
| | | | - Sally J Aldous
- Department of Cardiology (S.J.A., D.S., R.W.T.), Christchurch Hospital, New Zealand.,National Health and Medical Research Council Clinical Trials Centre, University of Sydney, New South Wales, Australia (S.J.L.)
| | | | - Michael W Ardagh
- Emergency Department (M.P.T., J.W.P., M.W.A., R.C., J.M.D., O.P.T., J.M.D.)
| | | | - Rosie Callender
- Emergency Department (M.P.T., J.W.P., M.W.A., R.C., J.M.D., O.P.T., J.M.D.)
| | | | | | | | | | - Joanne M Deely
- Emergency Department (M.P.T., J.W.P., M.W.A., R.C., J.M.D., O.P.T., J.M.D.)
| | | | | | | | - Christopher M A Frampton
- Department of Medicine, Christchurch Heart Institute, University of Otago, New Zealand (J.W.P., C.M.A.F., P.M.G., A.M.R., R.W.T.)
| | - Peter M George
- Department of Medicine, Christchurch Heart Institute, University of Otago, New Zealand (J.W.P., C.M.A.F., P.M.G., A.M.R., R.W.T.)
| | - Gregory J Hamilton
- Planning and Funding, Canterbury District Health Board, Christchurch, New Zealand (G.J.H.)
| | - Allan S Jaffe
- Department of Cardiology, Mayo Clinic, Rochester, MN (A.S.J.)
| | - Andrew J Kerr
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (A.J.K., W.F.P.)
| | - G Luke Larkin
- Department of Emergency Medicine (G.L.L.), Auckland University, New Zealand
| | | | - Timothy J E Matthews
- Department of General Medicine, Wairarapa Hospital, Masterton, New Zealand (T.J.E.M.)
| | - William A Parsonage
- Department of Cardiology (W.A.P.), Royal Brisbane and Women's Hospital, Australia
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (A.J.K., W.F.P.)
| | | | - Niels C van Pelt
- Department of Cardiology (N.C.v.P.), Middlemore Hospital, Auckland, New Zealand
| | | | - A Mark Richards
- Department of Medicine, Christchurch Heart Institute, University of Otago, New Zealand (J.W.P., C.M.A.F., P.M.G., A.M.R., R.W.T.).,Cardiovascular Research Institute, National University of Singapore (A.M.R.)
| | - Anthony G Scott
- Cardiology (A.G.S.), North Shore Hospital, Auckland, New Zealand
| | | | - David Smyth
- Department of Cardiology (S.J.A., D.S., R.W.T.), Christchurch Hospital, New Zealand
| | - Oliver P Thomas
- Emergency Department (M.P.T., J.W.P., M.W.A., R.C., J.M.D., O.P.T., J.M.D.)
| | - Andrew C Y To
- Department of Cardiology (A.C.Y.T.), Waitakere Hospital, Auckland, New Zealand
| | - Stephen A Du Toit
- Department of Biochemistry (S.A.D.T.), Waikato Hospital, Hamilton, New Zealand
| | - Richard W Troughton
- Department of Cardiology (S.J.A., D.S., R.W.T.), Christchurch Hospital, New Zealand.,Department of Medicine, Christchurch Heart Institute, University of Otago, New Zealand (J.W.P., C.M.A.F., P.M.G., A.M.R., R.W.T.)
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Swart EF, Miller DJ, Hickernell TR, Bozic KJ, Geller JA, Macaulay WB. Creation of an Online Wiki Improves Post-Operative Surgical Protocol Adherence in Arthroplasty Patients. J Arthroplasty 2017; 32:2319-2324.e6. [PMID: 28372915 DOI: 10.1016/j.arth.2017.02.081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 02/07/2017] [Accepted: 02/28/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Perioperative care pathways are tools used in high-volume clinical settings to standardize care, reduce variability, and improve outcomes. However, the mechanism by which the information is transmitted to other caregivers is often inconsistent and error-prone. At our institution, we developed an online, user-editable ("wiki") database to communicate post-operative protocols. The purpose of this study is to evaluate the hypothesis that implementation of the wiki would improve protocol adherence and reduce unintentional deviations inpatient care. METHODS We conducted a retrospective review of patients who underwent primary lower extremity arthroplasty at our institution during three 6-month time periods including immediately before, 6 months after, and 2 years following introduction of the wiki. Adherence to defined perioperative care pathways (laboratory studies, post-operative imaging, perioperative antibiotics, and inpatient pain medications) was compared between the groups. RESULTS After wiki implementation, adherence to protocols improved significantly for laboratory orders (P < .0001), imaging (P < .001), pain control regimen (P = .03), and overall protocol adherence (P < .001). Improvements were seen in some areas almost immediately, while others did not show improvements until 2 years after implementation. Costs associated with unnecessary testing were reduced by 82%. CONCLUSION Development of an online wiki for tracking post-operative protocols improves care pathway adherence and reduces variability in care while lowering costs associated with unnecessary testing, although some benefits may not be immediately realized. Several practical barriers to implementing the wiki are also discussed, along with proposed solutions.
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Affiliation(s)
- Eric F Swart
- Department of Orthopaedics and Rehabilitation, University of Massachusetts - Worcester, Worcester, Massachusetts
| | - Daniel J Miller
- Department of Orthopaedics, Columbia University Medical Center, New York, New York
| | - Thomas R Hickernell
- Department of Orthopaedics, Columbia University Medical Center, New York, New York
| | - Kevin J Bozic
- Department of Orthopaedic Surgery, University of Texas at Austin Dell Medical School, Austin, Texas; Department of Surgery and Perioperative Care, Dell Medical School at UT Austin, Austin, Texas
| | - Jeffrey A Geller
- Department of Orthopaedics, Columbia University Medical Center, New York, New York
| | - William B Macaulay
- Department of Orthopaedics, Columbia University Medical Center, New York, New York; Department of Orthopaedics, New York University, Langone Medical Center, New York, New York
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26
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Turini GA, Clark MA, Machan J, Tucci C, Renzulli JF. The Role of a Standardized Clinical Care Pathway in Patient Satisfaction and Quality of Life Outcomes after Robotic Assisted Laparoscopic Radical Prostatectomy. Urol Pract 2017; 4:232-238. [PMID: 37592643 DOI: 10.1016/j.urpr.2016.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Clinical care pathways reduce length of stay, variability in practice and costs, yet avoid compromising quality of care or increasing complications. In this study we describe a standardized care pathway, focusing on preoperative and postoperative education as well as immediate postoperative patient care after robotic assisted laparoscopic radical prostatectomy. METHODS A standardized robotic assisted laparoscopic radical prostatectomy care pathway was introduced at our institution in July 2014. A total of 108 men who underwent robotic assisted laparoscopic radical prostatectomy during 2014 were enrolled in this retrospective chart review and were subsequently mailed a quality of life survey. Data regarding length of stay and number of unplanned calls to the urology office or visits to the emergency department were collected from the chart review. The mailed survey was composed of original questions as well as questions adapted from the FACT-P (Functional Assessment of Cancer Therapy-Prostate). Patients who underwent robotic assisted laparoscopic radical prostatectomy between January and June 2014 were compared to those who underwent the same surgery between July and December 2014. RESULTS Demographically the 2 cohorts of men who underwent robotic assisted laparoscopic radical prostatectomy were similar. There was a significant reduction in postoperative length of stay in the post-care pathway cohort. Hospital readmissions were reduced by 75%. Despite earlier discharge home, there was no difference in the number of postoperative calls to the urology office or visits to the emergency department, or in overall patient satisfaction. CONCLUSIONS The implementation of a standardized care pathway for patients undergoing robotic assisted laparoscopic radical prostatectomy at our institution resulted in a reduced postoperative length of stay and readmission rate. Despite a more rapid discharge from the hospital, patient satisfaction and postoperative quality of life were not negatively impacted.
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Affiliation(s)
- George A Turini
- Minimally Invasive Urology Institute, Miriam Hospital, Brown University, Providence, Rhode Island
| | - Melissa A Clark
- Warren Alpert School of Medicine and Brown University School of Public Health, Providence, Rhode Island
| | - Jason Machan
- Biostatistics Core Research Services, The Rhode Island Hospital, Providence, Rhode Island
| | - Christopher Tucci
- Minimally Invasive Urology Institute, Miriam Hospital, Brown University, Providence, Rhode Island
| | - Joseph F Renzulli
- Minimally Invasive Urology Institute, Miriam Hospital, Brown University, Providence, Rhode Island
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27
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Cundy TP, Sierakowski K, Manna A, Cooper CM, Burgoyne LL, Khurana S. Fast-track surgery for uncomplicated appendicitis in children: a matched case-control study. ANZ J Surg 2016; 87:271-276. [PMID: 27599307 DOI: 10.1111/ans.13744] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/05/2016] [Accepted: 07/18/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Standardized post-operative protocols reduce variation and enhance efficiency in patient care. Patients may benefit from these initiatives by improved quality of care. This matched case-control study investigates the effect of a multidisciplinary criteria-led discharge protocol for uncomplicated appendicitis in children. METHODS Key protocol components included limiting post-operative antibiotics to two intravenous doses, avoidance of intravenous opioid analgesia, prompt resumption of diet, active encouragement of early ambulation and nursing staff autonomy to discharge patients that met assigned criteria. The study period was from August 2015 to February 2016. Outcomes were compared with a historical control group matched for operative approach. RESULTS Outcomes for 83 patients enrolled to our protocol were compared with those of 83 controls. There was a 29.2% reduction in median post-operative length of stay in our protocol-based care group (19.6 versus 27.7 h; P < 0.001). The rate of discharges within 24 h improved from 12 to 42%. There was no significant difference in complication rate (4.8 versus 7.2%; P = 0.51). Mean oral morphine dose equivalent per kilogram requirement was less than half (46%) that of control group patients (P < 0.001). Mean number of ondansetron doses was also significantly lower. Projected annual direct cost savings following protocol implementation was AUD$77 057. CONCLUSION Implementation of a criteria-led discharge protocol at our hospital decreased length of stay, reduced variation in care, preserved existing low morbidity, incurred substantial cost savings, and safely rationalized opioid and antiemetic medication. These protocols are inexpensive and offer tangible benefits that are accessible to all health care settings.
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Affiliation(s)
- Thomas P Cundy
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Kyra Sierakowski
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Alexandra Manna
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Celia M Cooper
- Department of Infectious Diseases, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Paediatrics, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Laura L Burgoyne
- Department of Children's Anaesthesia, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Sanjeev Khurana
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Paediatrics, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
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28
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Ferrante S, Bonacina S, Pozzi G, Pinciroli F, Marceglia S. A Design Methodology for Medical Processes. Appl Clin Inform 2016; 7:191-210. [PMID: 27081415 DOI: 10.4338/aci-2015-08-ra-0111] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 01/24/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Healthcare processes, especially those belonging to the clinical domain, are acknowledged as complex and characterized by the dynamic nature of the diagnosis, the variability of the decisions made by experts driven by their experiences, the local constraints, the patient's needs, the uncertainty of the patient's response, and the indeterminacy of patient's compliance to treatment. Also, the multiple actors involved in patient's care need clear and transparent communication to ensure care coordination. OBJECTIVES In this paper, we propose a methodology to model healthcare processes in order to break out complexity and provide transparency. METHODS The model is grounded on a set of requirements that make the healthcare domain unique with respect to other knowledge domains. The modeling methodology is based on three main phases: the study of the environmental context, the conceptual modeling, and the logical modeling. RESULTS The proposed methodology was validated by applying it to the case study of the rehabilitation process of stroke patients in the specific setting of a specialized rehabilitation center. The resulting model was used to define the specifications of a software artifact for the digital administration and collection of assessment tests that was also implemented. CONCLUSIONS Despite being only an example, our case study showed the ability of process modeling to answer the actual needs in healthcare practices. Independently from the medical domain in which the modeling effort is done, the proposed methodology is useful to create high-quality models, and to detect and take into account relevant and tricky situations that can occur during process execution.
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Affiliation(s)
- Simona Ferrante
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano , Milano, Italy
| | - Stefano Bonacina
- Health Informatics Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet , Stockholm, Sweden
| | - Giuseppe Pozzi
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano , Milano, Italy
| | - Francesco Pinciroli
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano, Italy; Engineering in Health and Wellbeing Research Group at the National Research Council of Italy IEIIT - Istituto di Elettronica e di Ingegneria dell'Informazione e delle Telecomunicazioni, Trieste, Italy
| | - Sara Marceglia
- Dipartimento di Ingegneria e Architettura, Università degli Studi di Trieste, Trieste, Italy; Clinical Center for Neurostimulation, Neurotechnology, and Movement Disorders Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milano, Italy
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McEvoy C, Wiles L, Bernhardsson S, Grimmer K. Triage for Patients with Spinal Complaints: A Systematic Review of the Literature. Physiother Res Int 2015; 22. [PMID: 26343816 DOI: 10.1002/pri.1639] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 05/20/2015] [Accepted: 07/03/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this study is to provide a systematic overview of the past decade of literature on processes of triage for patients with spinal pain, outcomes measured and markers of effectiveness. METHODS A systematic search of the literature with narrative synthesis of findings was conducted. Studies in English language of any design concerning spinal triage programmes for adults with acute or chronic spinal complaints were considered for inclusion. Electronic database searches were conducted in OVID, Medline, Embase, CINAHL, Health Source Nursing, Scopus and Web of Science. Additional references were sourced through pearling reference lists, and expert input. Findings were synthesized descriptively. RESULTS Of 216 potentially relevant records, 21 papers (20 studies) were included. There was little commonality in triage activities/programmes and outcomes, although physiotherapists were common members of triage programmes. Positive outcomes were reported most commonly for wait times, with several studies also reporting high levels of patient and physician satisfaction. Outcomes such as surgical conversion rates and selection accuracy were less clear. DISCUSSION Spinal triage programmes have the potential to improve efficiency of care for outpatients with spinal complaints. The evidence gaps in health outcomes, service models and cost effectiveness should be addressed by more robust prospective research designs. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Claire McEvoy
- International Centre for Allied Health Evidence, University of South Australia, Adelaide, Australia
| | - Louise Wiles
- International Centre for Allied Health Evidence, University of South Australia, Adelaide, Australia
| | - Susanne Bernhardsson
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
- Närhälsan Hönö/Öckerö Rehabilitation, Region Västra Götaland, Sweden
| | - Karen Grimmer
- International Centre for Allied Health Evidence, University of South Australia, Adelaide, Australia
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Musser JE, Assel MJ, Meeks JJ, Sjoberg DD, Vickers AJ, Coleman JA, Eastham JA, Parra RO, Scardino PT, Touijer KA, Laudone VP. Ambulatory Extended Recovery: Safely Transitioning to Overnight Observation for Minimally Invasive Prostatectomy. Urol Pract 2015; 2:121-125. [PMID: 37559295 DOI: 10.1016/j.urpr.2014.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION We evaluated the safety and efficacy of a clinical pathway designed and implemented to transition inpatient minimally invasive radical prostatectomy to a procedure with overnight observation. METHODS In April 2011 ambulatory extended recovery was implemented at our institution. This was a multidisciplinary program of preoperative teaching and postoperative care for patients undergoing minimally invasive radical prostatectomy. We compared the risk of requiring a more than 1-night hospital stay by patients treated with surgery the year before the program vs those treated after the program was initiated, adjusting for age, ASA® status and surgery type. We also examined the rates of readmission and urgent care visits within 48 hours, and 7 and 30 days before and after the program began. RESULTS The proportion of patients who stayed longer than 1 night was 53% in the year before initiating the ambulatory extended recovery program vs 8% during the program, representing an adjusted absolute risk decrease of 45% (95% CI 39-50, p <0.0001). There was no important predictor of a greater than 1-night length of stay among ambulatory extended recovery patients. Rates of readmission and urgent care visits were slightly lower during the ambulatory extended recovery phase with no significant difference between the groups. CONCLUSIONS The ambulatory extended recovery program successfully transitioned most patients to a 1-night hospital stay without resulting in an increased rate of readmission or urgent care visits.
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Affiliation(s)
- John E Musser
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa J Assel
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joshua J Meeks
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel D Sjoberg
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew J Vickers
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan A Coleman
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - James A Eastham
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Raul O Parra
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter T Scardino
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karim A Touijer
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vincent P Laudone
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
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Tarin T, Feifer A, Kimm S, Chen L, Sjoberg D, Coleman J, Russo P. Impact of a common clinical pathway on length of hospital stay in patients undergoing open and minimally invasive kidney surgery. J Urol 2013; 191:1225-30. [PMID: 24270130 DOI: 10.1016/j.juro.2013.11.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2013] [Indexed: 01/14/2023]
Abstract
PURPOSE Clinical pathways are designed to reduce variability in patient care practices and improve clinical outcomes. We evaluated the effect of implementing a clinical care pathway on length of stay in patients undergoing kidney surgery. MATERIALS AND METHODS After receiving institutional review board approval we evaluated prospective data on consecutive cases of partial and radical nephrectomy performed at our institution from 2000 to 2011. We identified 1,775 partial nephrectomies (1,449 open and 326 minimally invasive) and 1,025 radical nephrectomies (857 open and 168 minimally invasive). We used multivariate linear regression to test for an interaction between procedure type and surgery before vs after the clinical pathway was begun. RESULTS Median length of stay decreased 40% (from 5 to 3 days) for open surgery and 33% (from 3 to 2 days) for minimally invasive surgery after clinical pathway implementation. Length of stay in patients treated with minimally invasive or open partial nephrectomy and open radical nephrectomy decreased while it remained stable in those who underwent minimally invasive radical nephrectomy. The difference in length of stay between open and minimally invasive partial nephrectomy before and after implementing the clinical pathway decreased by 1.5 days (95% CI 0.56-2.5, p = 0.002). At 30 days postoperatively major complication rates remained similar. CONCLUSIONS The clinical pathway resulted in a significantly shorter length of stay in patients treated with partial and radical nephrectomy without a discernible impact on safety or quality of care. Clinical pathways for kidney surgery should be used and continually optimized to enhance efficiency, patient safety and outcomes.
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Affiliation(s)
- Tatum Tarin
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Andrew Feifer
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Simon Kimm
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ling Chen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan Coleman
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul Russo
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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32
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Abstract
The nurses play an important role in the overall management of a burn patient. They must be well versed with the various protocols available that can be used to rationally manage a given situation. The management not only involves medical care but also a psychological assessment of the victim and the family. The process uses a scientific method to combine systems theory with the art of nursing, entailing both problem solving techniques and a decision making process. It involves assessment of the patient to arrive at a diagnosis and then determining the patient goals.An action plan is implemented and is evaluated in the context of patient response. The article discusses many such scenarios in burn patients and outlines the nursing care plans.
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33
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Abstract
Objective. To evaluate the effectiveness of a care pathway for the use of electroconvulsive therapy (ECT) in a UK psychiatric inpatient unit. Methods. A completed clinical audit cycle of the care pathway and variance from it. Results. Sixty courses of treatment were reviewed. All were given for severe depressive disorder. Consent was recorded for all but one course. Clinical assessments were completed for 96% during and 50% after treatment. Conclusions. Use of a care pathway enhanced aspects of the clinical practice of ECT, although the overall effect was inconsistent. ECT was not used to treat schizophrenia. Maintenance ECT continues to be used despite the recent NICE guidance on this subject. The care pathway ensured regular clinical assessment of patients during their courses of ECT.
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Affiliation(s)
- Demi Onalaja
- Coventry & Warwickshire Partnership NHS Trust, Caludon Centre, Coventry, UK
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